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Summary Table of U.S. Government Accountability Office Reports Relevant to Adjudication of Veterans’ Disability Claims
TABLE N-1 Summary Table of U.S. Government Accountability Office Reports Relevant to Adjudication of Veterans’ Disability Claims
Title (Year) | Purpose of Report | Findings | Recommendations |
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Opportunities Exist to Better Ensure Successful Appeals Reform (2018) | The Veterans Appeals Improvement and Modernization Act of 2017 makes changes to the VA’s current (legacy) appeals process, giving veterans new options to have their claims further reviewed by VBA or appeal directly to the board. The act requires the VA to submit to Congress and GAO a plan for implementing a new appeals process, and includes a provision for GAO to assess the VA’s plan. This testimony focuses on the extent to which the VA’s plan (1) addresses the required elements in the act and (2) reflects sound planning practices identified in prior GAO work. | The VA’s plan for implementing a new disability appeals process while attending to appeals in the current process addresses most, but not all, elements required by the Veterans Appeals Improvement and Modernization Act of 2017. The VA’s appeals plan addresses 17 of 22 required elements, partially addresses 4, and does not address 1. For example, not addressed is the required element to include the resources needed by the Veterans Benefits Administration (VBA) and the Board of Veterans’ Appeals to implement the new appeals process and address legacy appeals under the current process. The VA’s appeals plan reflects certain sound planning practices, but it could benefit from including important details in several key planning areas: performance measurement, project management, and risk assessment. |
GAO recommends that the VA:
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Some Progress, But Further Steps | In March 2018, GAO found that the VA could help ensure successful | Since the March 2018 report, the VA has updated its plan and taken some steps to address aspects of |
Title (Year) | Purpose of Report | Findings | Recommendations |
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Needed to Improve Appeals Reform Planning (2018) | implementation of appeals reform by addressing gaps in planning and made four recommendations, with which the VA agreed (See Opportunities Exist to Better Ensure Successful Appeals Reform). This testimony focuses on the steps the VA has taken to address GAO’s recommendations and what aspects remain unaddressed. |
these recommndations, but further steps are needed:
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Title (Year) | Purpose of Report | Findings | Recommendations |
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Preparations for Transitioning to a New Electronic Health Record System Are Ongoing (2018) | The VA relies on its health information system, the Veterans Health Information Systems and Technology Architecture (VistA), to provide health care services. However, the system is more than 30 years old, is costly to maintain, and does not support | GAO’s preliminary results indicate that the VA is working to define VistA and identify system components to be replaced by the new system. However, according to VA officials, there is no single information source that fully defines the scope of VistA. This situation is partly due to differences in VistA at various facilities. In the absence of a complete definition of VistA, program | In 2011, GAO reported on nine common factors critical to the success of major information technology (IT) acquisitions. Such factors include ensuring the active engagement of senior officials with stakeholders |
Title (Year) | Purpose of Report | Findings | Recommendations |
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interoperability with DoD and private health care providers. Since 2001, the VA has pursued multiple efforts to modernize the system. In June 2017, the VA announced plans to acquire the same system—the Cerner system—that DoD is implementing. GAO summarizes observations from its ongoing review of VistA. | officials have taken a number of steps to define the system’s scope and to identify the components that the new system will replace. These steps have included conducting analyses, performing preliminary site (medical facility) assessments, and planning for a detailed assessment of each site where the new system will be deployed. | and having qualified, experienced program staff. These critical success factors can serve as a model of best practices that the VA could apply to enhance the likelihood that the acquisition of a new electronic health record system will be successfully achieved. | |
Better Data and Evaluation Could Help Improve Physician Staffing, Recruitment, and Retention Strategies (2017) | This report addresses (1) VHA data on how many mission-critical physicians provide care, (2) the extent to which VHA measures the workload and productivity of mission-critical physicians; and (3) what evaluations have been done on the effectiveness of VHA’s recruitment and retention strategies for all physicians. |
GAO identified the following issues:
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GAO makes five recommendations, including that the VA develop a process to count all physicians, provide guidance on productivity measurement, and evaluate its physician recruitment and retention strategies. The VA concurred with four of the five recommendations, but not with the one to accurately count all physicians, stating that its workforce assessment tools are sufficient. However, GAO maintains that this is essential for effective workforce planning. |
Title (Year) | Purpose of Report | Findings | Recommendations |
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Additional Planning Would Enhance Efforts to Improve the Timeliness of Appeals Decisions (2017) | This report examines the VA’s approaches to address the challenges it identified as contributing to lengthy appeals processing times and the extent to which those approaches are consistent with sound planning practices. |
The VA has taken actions related to increasing staff, reforming the process, and updating IT, which are consistent with relevant sound planning practices. However, gaps in planning exist, thereby reducing the agency’s ability to ensure that these actions will improve the timeliness of disability appeals decisions.
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GAO made five recommendations to the VA:
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Title (Year) | Purpose of Report | Findings | Recommendations |
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action is needed on all five recommendations to improve VA’s ability to successfully implement reforms, as discussed in the report. | ||
Improvements Needed for VA to Better Understand, Process, and Communicate Decisions on Claims (2017) | Recently, questions have been raised about whether the VA is processing GWI (Gulf War illness) claims correctly. GAO was asked to review the VA’s handling of these claims. This report examines (1) recent trends in GWI disability claims, (2) challenges associated with accurately processing and clearly communicating decisions on GWI claims, and (3) how the VA uses GWI research to inform the disability compensation program. | The VA’s ability to accurately process GWI claims is hampered by inadequate training, and its decision letters for denied claims do not communicate key information to veterans. The VA claims rating staff often rely on VA medical examiners to assess a veteran’s disability before a decision can be made on a claim. VA medical examiners told GAO that conducting Gulf War general medical exams is challenging because of the range of symptoms that could qualify as GWI. The VA has developed elective GWI training for its medical examiners, but only 10 percent of examiners had taken the training as of February 2017. Federal internal control standards call for adequate training for staff so they can correctly carry out an agency’s procedures. Medical examiners who do not take this GWI-specific training may not be able to provide the information that VA staff need to correctly decide whether to grant a veteran’s claim. Once a determination is made, VA regulations also require clear |
GAO recommends that VHA:
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Title (Year) | Purpose of Report | Findings | Recommendations |
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explanations to veterans regarding claim decisions. GAO found that decision letters for GWI claims do not always include key information on why the claim was denied. |
research to help the VA achieve this goal. |
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Management Attention Needed to Improve Critical System Modernizations, Consolidate Data Centers, and Retire Legacy Systems (2017) | The use of IT is crucial to helping the VA effectively serve the nation’s veterans, and each year the department spends over $4 billion on IT. However, over many years the VA has had difficulty managing its information systems. This statement summarizes results from key GAO reports related to increasing electronic health record interoperability between the VA and DoD; system challenges that have contributed to GAO’s designation of VA health care as a high-risk area; and the VA’s development of its system for processing disability benefits, data center consolidation, and legacy systems. | GAO noted in July 2016 that the VA had moved forward with an effort to modernize its health information system, VistA, but that the department is uncertain of its long-term plan for addressing its electronic health record system needs beyond fiscal year 2018. Beyond modernizing VistA, GAO reported in August 2015 that the VA and DoD had not identified outcome-oriented goals and metrics to clearly define what they aim to achieve from their efforts to increase electronic health record interoperability (i.e., the electronic exchange and use of health records) between the two departments. Moreover, the VA has begun to modernize VistA separately from DoD’s planned acquisition of a commercially available electronic health record system, even though both departments have many health care business needs in common. | GAO has made numerous recommendations to the VA to improve the modernization of its IT systems. For example, GAO has recommended that the VA develop goals and metrics for determining the extent to which its modernized electronic health record system is achieving interoperability with DoD’s; to address challenges associated with modernizing its scheduling system; to address shortcomings with VBMS planning and implementation; to take actions to improve progress in data center optimization; and to modernize or replace obsolete legacy IT systems. |
Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency (2017) | Beginning in fiscal year 2013, the VA began implementing clinical productivity metrics to measure physician providers’ time and effort to deliver various procedures in 32 clinical specialties. In addition, the VA developed 12 statistical models to measure clinical efficiency at the VA’s medical centers (VAMCs). |
Limitations with the VA’s metrics and models:
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To improve the completeness of the VA’s productivity metrics, we recommended that the VA expand existing productivity metrics to track the productivity of all providers of care to veterans by, for example, including contract physicians who are |
Title (Year) | Purpose of Report | Findings | Recommendations |
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Under the models, the VA calculates each VAMC’s use and expenditures for different high-volume or high-expenditure components of health care delivery, such as emergency department and urgent care, and determines the extent to which use and expenditures differ from expected levels. This testimony addresses (1) whether the VA’s clinical productivity metrics and efficiency models provide complete and accurate information on provider productivity and VAMC efficiency and (2) the VA’s efforts to monitor and improve clinical productivity and efficiency. |
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not VA employees as well as advanced practice providers acting as sole providers. In addition, to improving the accuracy of the VA’s productivity metrics and efficiency models, we recommended that the VA help ensure the accuracy of underlying workload and staffing data by, for example, developing training for all providers on coding clinical procedures. The VA agreed in principle with our recommendations but did not provide information on how it plans to make improvements. | |
Ongoing Efforts Can Be Improved; Goals Are Needed to Promote Increased User Satisfaction (2016) | This statement summarizes GAO’s September 2015 report (GAO-15-582) on (1) the VA’s progress toward completing the development and implementation of the VBMS and (2) the extent to which users report satisfaction with the system. | As GAO reported in September 2015, VBA has made progress in developing and implementing the VBMS, with deployment of the initial version of the system to all of its regional offices as of June 2013. Since then, VBA has continued developing and implementing additional system functionality and enhancements that support the electronic processing of disability compensation claims. As a |
Three areas could benefit from increased management attention:
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Title (Year) | Purpose of Report | Findings | Recommendations |
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result, 95 percent of records related to veterans’ disability claims are electronic and reside in the system. However, VBMS is not yet able to fully support disability and pension claims or appeals processing. While the Under Secretary for Benefits stated in March 2013 that the development of VBMS was expected to be completed in 2015, the implementation of functionality to fully support electronic claims processing has been delayed beyond 2015. In addition, VBA has not yet produced a plan that identifies when the system will be completed. Accordingly, holding the VA management accountable for meeting a time frame and for demonstrating progress will be difficult. |
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Ongoing Development and Implementation Can Be Improved; Goals Are Needed to Promote Increased User Satisfaction (2015) | GAO (1) assessed the VA’s progress toward completing the development and implementation of VBMS and (2) determined to what extent users report satisfaction with the system. To do so, GAO reviewed relevant program documentation, administered a survey to a stratified random sample of about 3,500 users, and interviewed appropriate VA officials. | VBA has made progress in developing and implementing the VBMS, with deployment of the system to all of its regional offices as of June 2013. While 95 percent of records related to veterans’ disability claims are electronic and reside in the system, additional capabilities have not yet been completed, such as automation of the steps associated with a veteran’s request for an increase in benefits. Furthermore, VBA has not yet developed and implemented pension processing capabilities in VBMS, nor has it articulated when the system will support appeals processing. | See Ongoing Efforts Can Be Improved; Goals Are Needed to Promote Increased User Satisfaction (2016) |
Improvements Could Further Enhance Quality | This report evaluates (1) the extent to which VBA effectively measures and reports the accuracy of its disability compensation claim | VBA’s dual approach for measuring accuracy is designed to provide additional information to better target quality improvement efforts, but its methods and practices lack rigor and transparency, thereby |
Leverage appropriate expertise to help VBA do each of the following:
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Title (Year) | Purpose of Report | Findings | Recommendations |
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Assurance Efforts (2014) | decisions and (2) whether VBA’s other quality assurance activities are coordinated and effective. GAO analyzed VBA claims and STAR accuracy data from fiscal year 2013 (the most recent fiscal year for which complete data are available); reviewed relevant federal laws, VBA guidance, and other documents relevant to quality assurance activities; and interviewed VBA staff from headquarters and four VBA regional offices (selected to achieve variety in geography, workload, and accuracy rates) as well as veteran service organization officials. | undermining the usefulness and credibility of its measures. By not leveraging a statistician or otherwise following statistical practices in developing accuracy estimates, VBA is producing and relying on inaccurate estimates to make important internal management decisions. Similarly, by using a one-size sampling methodology, VBA is unnecessarily expending limited resources that could be used elsewhere. The systematic exclusion of redistributed claims and those moved between offices further calls into question the rigor of its accuracy estimates. Finally, VBA’s reporting of its two accuracy metrics lacks sufficient transparency to help members of Congress and other stakeholders fully understand the differences and limitations of each and thus may undermine their trust in VBA’s reported performance. VBA has enhanced and coordinated other aspects of its quality assurance framework, but shortcomings in implementation and evaluation detract from their overall effectiveness. For example, although VBA is disseminating the results of national STAR reviews and consistency studies and local quality review teams (QRTs) are using those results to focus related training or guidance to claims processing staff, until centralized guidance is consolidated and streamlined, staff lack ready access to information that will help them prevent errors. Moreover, absent adequate system capabilities to support local quality reviews, QRTs are unable to stop incorrect decisions from being finalized, and may not be aware of error trends that could be mitigated through training or other corrective action. Finally, although some of its quality assurance activities are |
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Title (Year) | Purpose of Report | Findings | Recommendations |
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relatively new, VBA lacks specific plans to evaluate their effectiveness and may miss opportunities to further improve or target these activities to more error-prone areas. In general, unless VBA takes steps to improve the rigor of all its quality assurance methods and practices, VBA may find progress toward achieving its goal of 98 percent accuracy in fiscal year 2015 illusive—especially in the face of challenging workloads, limited resources, and expectations of timely claim decisions. |
evaluate the effectiveness of quality assurance activities to identify opportunities to improve or better target these activities. |
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Actions Needed to Address Hurdles Facing Program Modernization (2012) | Concerns exist that the VA’s rating schedule—the criteria used to assign degree of work disability—is not consistent with changes in medicine and the labor market. GAO examined (1) the VA’s progress in revising its rating schedule with updated medical and economic information and (2) the opportunities and challenges of various policy approaches proposed by commissions and others for updating the VA’s disability benefits structure. | The VA initiated a comprehensive effort in 2009 to revise its disability rating schedule with both updated medical and earnings information, but it faces hurdles with several key aspects. The current revision effort takes a more comprehensive and empirical approach than the VA’s past efforts. The VA has hired full-time staff to revise the rating schedule’s medical information and plans to conduct studies to evaluate veterans’ average loss of earnings in today’s economy. As part of this effort, the VA is considering modifying the rating schedule—currently based largely on the degree of medical severity—to include a veteran’s ability to function in the workplace. Moving in this direction is more consistent with how experts conceive of disability. | Conduct focused studies on various approaches to modernize disability benefits and, if necessary, propose relevant legislation. GAO is also making several recommendations to improve the VA’s capacity to revise the rating schedule now and in the future. These include completing plans for conducting earnings loss studies and developing a written strategy for implementing revisions to the rating schedule. |
VA Needs Plan for Assessing Consistency of Decisions (2004) | Key questions: (1) Since the issuance of GAO’s 2002 report, what actions has the VA taken to assess the consistency of regional office decisions on disability compensation claims? (2) To what extent does the VA have program data that can be used to measure the | Since the issuance of GAO’s 2002 report, the VA has not systematically assessed the consistency of regional office decisions on specific impairments. Existing compensation program data have limitations that preclude identifying indications of decision-making inconsistency among regional offices. However, the VA is implementing a new data collection system that may afford an | Develop a plan, and include it in the VA’s annual performance plan, that details how the VA will: (1) use data collected through RBA 2000 to identify indications of possible inconsistencies among regional offices in the |
Title (Year) | Purpose of Report | Findings | Recommendations |
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consistency of decision making among regional offices? | opportunity to identify indications of inconsistency in the future. | award and denial of benefits for specific impairments and (2) conduct systematic studies of consistency for specific impairments for which RBA 2000 data reveal indications of inconsistencies among decisions made by the regional offices. | |
Problems and Challenges Facing Disability Claims Processing (2000) | Focus on four key areas related to compensation claims processing: (1) longstanding performance problems, (2) claims-processing complexities, (3) challenges to improving performance, and (4) VBA’s initiatives to improve performance. | VBA’s problems with large backlogs and long waits for decisions have not yet improved, despite years of studying these problems. VBA’s new quality measurement system shows that nearly one-third of decisions are incorrect or have technical or procedural errors. Many performance problems stem from the process’s complexity, which is growing as the number of service-connected disabilities per veteran increases and judicial review requires more procedures and documentation. Although VBA has initiated a number of efforts to streamline its claims-processing performance, it is unclear how much improvement will be gained. | VBA may need to collect and analyze additional case-specific data to better understand its claims-processing problems and better target its corrective actions. Furthermore, because some issues affecting VBA’s performance are a function of program design, more fundamental changes may have to be made. |