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N Summary Table of U.S. Government Accountability Office Reports Relevant to Adjudication of Veteransâ Disability Claims TABLE N-1 Summary Table of U.S. Government Accountability Office Reports Relevant to Adjudication of Veteransâ Disability Claims Title (Year) Purpose of Report Findings Recommendations Opportunities The Veterans Appeals Improvement The VAâs plan for implementing a new disability GAO recommends that the Exist to Better and Modernization Act of 2017 appeals process while attending to appeals in the VA: Ensure Successful makes changes to the VAâs current current process addresses most, but not all, â¢ Fully address all legally Appeals Reform (legacy) appeals process, giving elements required by the Veterans Appeals required elements in its (2018) veterans new options to have their Improvement and Modernization Act of 2017. The appeals plan 187 claims further reviewed by VBA or VAâs appeals plan addresses 17 of 22 required â¢ Articulate how it will appeal directly to the board. The act elements, partially addresses 4, and does not monitor and assess the requires the VA to submit to address 1. For example, not addressed is the new appeals process as Congress and GAO a plan for required element to include the resources needed compared to the legacy implementing a new appeals by the Veterans Benefits Administration (VBA) process process, and includes a provision and the Board of Veteransâ Appeals to implement â¢ Augment its master for GAO to assess the VAâs plan. the new appeals process and address legacy appeals schedule for This testimony focuses on the extent under the current process. The VAâs appeals plan implementation to which the VAâs plan (1) reflects certain sound planning practices, but it â¢ More fully address risk addresses the required elements in could benefit from including important details in the act and (2) reflects sound several key planning areas: performance (See Some Progress, But planning practices identified in prior measurement, project management, and risk Further Steps Needed to GAO work. assessment. Improve Appeals Reform Planning for the VAâs Progress) Some Progress, In March 2018, GAO found that the Since the March 2018 report, the VA has updated But Further Steps VA could help ensure successful its plan and taken some steps to address aspects of
188 Title (Year) Purpose of Report Findings Recommendations Needed to implementation of appeals reform these recommndations, but further steps are Improve Appeals by addressing gaps in planning and needed: Reform Planning made four recommendations, with â¢ Address all legally required elements. GAO (2018) which the VA agreed (See reported that the VAâs plan did not address one and Opportunities Exist to Better Ensure only partially addressed four of 22 elements Successful Appeals Reform). This required by the Veterans Appeals Improvement testimony focuses on the steps the and Modernization Act of 2017, and it VA has taken to address GAOâs recommended that the VA fully address them all. recommendations and what aspects In a May 2018 update to its plan, the VA took steps remain unaddressed. to address the five elements, such as developing productivity projections and a model to forecast resource needs for processing appeals. These steps address one element related to projecting productivity and partially address the four remaining elements. â¢ Articulate performance measurement. GAO also recommended that the VA clearly articulate how it will monitor and assess the new appeals process relative to the legacy process. This recommendation includes specifying timeliness goals for five new appeals options to be made available to veterans as well as additional goals or measures of performance, such as accuracy in processing appeals. The VAâs updated plan states that the agency will develop goals and measures for all appeals options after fully implementing appeals reform. Contrary to sound planning practices, it does not articulate these performance goals and measures now, which would provide a vision for what successful implementation would look like. Lacking this vision, the VA does not have an âend stateâ to guide its implementation and help establish accountability. â¢ Augment project plan. GAO recommended that the VA augment its master schedule for
Title (Year) Purpose of Report Findings Recommendations implementing appeals reform to include all key activities and reflect other sound practices for guiding implementation and establishing accountability. Although the VAâs May 2018 updated master schedule added activities, it omitted a pilot test of the new Board of Veteransâ Appeals options. More generally, the plan does not reflect interdependencies among activities. Until all key activities are accounted for and the master schedule reflects sound practices, the VA cannot provide reasonable assurance that it has the essential information needed to manage its appeals reform implementation. â¢ Address risk fully. GAO recommended that the VAâs appeals plan more fully address risks in implementing a new process by, for example, testing all appeals options prior to full implementation. In its updated plan, the VA stated it will pilot all five new appeals options. By taking these steps, the VA should be better positioned to assess implementation risks. However, the updated plan does not have well-defined, measurable criteria for assessing lessons learned from these pilots and does not articulate how well these lessons translate to a broader context. Taking these steps would improve the VAâs ability to assess and mitigate risks as it implements its reforms. Preparations for The VA relies on its health GAOâs preliminary results indicate that the VA is In 2011, GAO reported on Transitioning to a information system, the Veterans working to define VistA and identify system nine common factors critical New Electronic Health Information Systems and components to be replaced by the new system. to the success of major Health Record Technology Architecture (VistA), to However, according to VA officials, there is no information technology (IT) System Are provide health care services. single information source that fully defines the acquisitions. Such factors Ongoing (2018) However, the system is more than scope of VistA. This situation is partly due to include ensuring the active 30 years old, is costly to maintain, differences in VistA at various facilities. In the engagement of senior and does not support absence of a complete definition of VistA, program officials with stakeholders 189
190 Title (Year) Purpose of Report Findings Recommendations interoperability with DoD and officials have taken a number of steps to define the and having qualified, private health care providers. Since systemâs scope and to identify the components that experienced program staff. 2001, the VA has pursued multiple the new system will replace. These steps have These critical success factors efforts to modernize the system. In included conducting analyses, performing can serve as a model of best June 2017, the VA announced plans preliminary site (medical facility) assessments, and practices that the VA could to acquire the same systemâthe planning for a detailed assessment of each site apply to enhance the Cerner systemâthat DoD is where the new system will be deployed. likelihood that the acquisition implementing. of a new electronic health GAO summarizes observations record system will be from its ongoing review of VistA. successfully achieved. Better Data and This report addresses (1) VHA data GAO identified the following issues: GAO makes five Evaluation Could on how many mission-critical â¢ Incomplete information on the number of recommendations, including Help Improve physicians provide care, (2) the physicians. VHA is unable to accurately count the that the VA develop a Physician Staffing, extent to which VHA measures the total number of physicians who provide care in its process to count all Recruitment, and workload and productivity of VA medical centers (VAMCs). VHA has data on physicians, provide guidance Retention mission-critical physicians; and (3) the number of mission-critical physicians it on productivity measurement, Strategies (2017) what evaluations have been done on employs (more than 11,000) and on those and evaluate its physician the effectiveness of VHAâs physicians who serve on a fee-basis (about 2,800). recruitment and retention recruitment and retention strategies However, VHA lacks data on the number of strategies. The VA concurred for all physicians. contract physicians and physician trainees. Five of with four of the five the six VAMCs in GAOâs review used contract recommendations, but not physicians or physician trainees to meet their with the one to accurately staffing needs, but VHA has no information on the count all physicians, stating extent to which VAMCs nationwide use these that its workforce assessment arrangements. tools are sufficient. However, â¢ Inconsistent productivity data. VHA measures GAO maintains that this is productivity for some mission-critical physician essential for effective occupations; however, mental health departments workforce planning. receive conflicting sets of productivity metrics from two VHA officesâthe Office of Productivity, Efficiency, and Staffing and the Office of Mental Health Operations. VHA officials said that the two offices use differing data to serve different purposes and acknowledged that while information on how to interpret the two sets of productivity
Title (Year) Purpose of Report Findings Recommendations data is available, VAMC officials may find the data confusing. â¢ Lack of a comprehensive evaluation of its recruitment and retention strategies. VHA has not evaluated the effectiveness of its physician recruitment and retention strategies. Additional This report examines the VAâs The VA has taken actions related to increasing GAO made five Planning Would approaches to address the staff, reforming the process, and updating IT, recommendations to the VA: Enhance Efforts to challenges it identified as which are consistent with relevant sound planning â¢ Apply sensitivity analyses Improve the contributing to lengthy appeals practices. However, gaps in planning exist, thereby when projecting staff Timeliness of processing times and the extent to reducing the agencyâs ability to ensure that these needs, Appeals Decisions which those approaches are actions will improve the timeliness of disability â¢ Develop a more timely (2017) consistent with sound planning appeals decisions. and detailed workforce practices. â¢ Increase staff: The VA determined that staff plan, resources have not sufficiently kept pace with â¢ Develop a robust plan for increased pending appeals and concluded that monitoring process additional staff are needed, particularly at the reform, board, to improve timeliness and reduce its appeals â¢ Develop a strategy for inventory. The board received approval to hire assessing process reform, more staff in fiscal year 2017, and it expects to and need an additional hiring surge beginning in fiscal â¢ Create a schedule for IT year 2018. As of October 2016, officials estimated improvements that takes that if the agency does not take any action, such as into account the plans for increasing staff in 2018, veterans may have to wait potential process reform. an average of 8.5 years by fiscal year 2026 to have their appeals resolved. The VA concurred in Consistent with sound workforce planning principle with the five practices, the VA modeled different options for recommendations, but it increasing staff levels to support its conclusion that believes it has met the intent staff increases in conjunction with process change of those recommendations would reduce the appeals inventory sooner. and does not need to take However, contrary to sound practices, the VA often additional action. GAO used fixed estimates for key variables in its disagrees andâwhile modelsâsuch as staff productivityârather than a recognizing VAâs ongoing range of estimates (sensitivity analysis) to effortsâbelieves further 191
192 Title (Year) Purpose of Report Findings Recommendations understand the effect that variation in these key action is needed on all five variables could have on staffing needs. recommendations to improve â¢ Reform process: The VA determined that new VAâs ability to successfully evidenceâwhich a veteran can submit at any point implement reforms, as during his or her appealâinefficiently causes an discussed in the report. additional round of reviews and thus delays appeals decisions, and in response it proposed legislation (not enacted) to streamline the process. Consistent with sound practices for process redesign, the VA worked with veterans service organizations (VSOs) and other key stakeholders in developing the proposal and continued to update VSOs about the development of its implementation plans. Improvements Recently, questions have been The VAâs ability to accurately process GWI claims GAO recommends that VHA: Needed for VA to raised about whether the VA is is hampered by inadequate training, and its â¢ Require medical Better Understand, processing GWI (Gulf War illness) decision letters for denied claims do not examiners to complete Process, and claims correctly. GAO was asked to communicate key information to veterans. The VA training, such as the 90- Communicate review the VAâs handling of these claims rating staff often rely on VA medical minute GWI web-based Decisions on claims. examiners to assess a veteranâs disability before a course, before conducting Claims (2017) This report examines (1) recent decision can be made on a claim. VA medical these exams. trends in GWI disability claims, (2) examiners told GAO that conducting Gulf War â¢ Provide more complete challenges associated with general medical exams is challenging because of information to veterans accurately processing and clearly the range of symptoms that could qualify as GWI. whose GWI claims are communicating decisions on GWI The VA has developed elective GWI training for denied, and claims, and (3) how the VA uses its medical examiners, but only 10 percent of â¢ Document a plan to GWI research to inform the examiners had taken the training as of February develop a single case disability compensation program. 2017. Federal internal control standards call for definition of GWI. This adequate training for staff so they can correctly plan should include near- carry out an agencyâs procedures. Medical and long-term specific examiners who do not take this GWI-specific actions, such as analyzing training may not be able to provide the information and leveraging that VA staff need to correctly decide whether to information in existing grant a veteranâs claim. Once a determination is datasets and identifying made, VA regulations also require clear any areas for future
Title (Year) Purpose of Report Findings Recommendations explanations to veterans regarding claim decisions. research to help the VA GAO found that decision letters for GWI claims do achieve this goal. not always include key information on why the claim was denied. Management The use of IT is crucial to helping GAO noted in July 2016 that the VA had moved GAO has made numerous Attention Needed the VA effectively serve the forward with an effort to modernize its health recommendations to the VA to Improve nationâs veterans, and each year the information system, VistA, but that the department to improve the modernization Critical System department spends over $4 billion is uncertain of its long-term plan for addressing its of its IT systems. For Modernizations, on IT. However, over many years electronic health record system needs beyond fiscal example, GAO has Consolidate Data the VA has had difficulty managing year 2018. Beyond modernizing VistA, GAO recommended that the VA Centers, and its information systems. reported in August 2015 that the VA and DoD had develop goals and metrics for Retire Legacy This statement summarizes results not identified outcome-oriented goals and metrics determining the extent to Systems (2017) from key GAO reports related to to clearly define what they aim to achieve from which its modernized increasing electronic health record their efforts to increase electronic health record electronic health record interoperability between the VA and interoperability (i.e., the electronic exchange and system is achieving DoD; system challenges that have use of health records) between the two interoperability with DoDâs; contributed to GAOâs designation departments. Moreover, the VA has begun to to address challenges of VA health care as a high-risk modernize VistA separately from DoDâs planned associated with modernizing area; and the VAâs development of acquisition of a commercially available electronic its scheduling system; to its system for processing disability health record system, even though both address shortcomings with benefits, data center consolidation, departments have many health care business needs VBMS planning and and legacy systems. in common. implementation; to take actions to improve progress in data center optimization; and to modernize or replace obsolete legacy IT systems. Improvements Beginning in fiscal year 2013, the Limitations with the VAâs metrics and models: To improve the completeness Needed in Data VA began implementing clinical â¢ Productivity metrics are not complete because of the VAâs productivity and Monitoring of productivity metrics to measure they do not account for all providers or clinical metrics, we recommended Clinical physician providersâ time and effort services. Due to systems limitations, the metrics do that the VA expand existing Productivity and to deliver various procedures in 32 not capture all types of providers who deliver care productivity metrics to track Efficiency (2017) clinical specialties. In addition, the at VAMCs, including contract physicians and the productivity of all VA developed 12 statistical models advanced practice providers, such as nurse providers of care to veterans to measure clinical efficiency at the practitioners, serving as sole providers. The VA by, for example, including 193 VAâs medical centers (VAMCs). central office officials explained that the VA data contract physicians who are
194 Title (Year) Purpose of Report Findings Recommendations Under the models, the VA system limitations and other factors have made it not VA employees as well as calculates each VAMCâs use and difficult for the VAâs productivity metrics to advanced practice providers expenditures for different high- capture the workload for all types of providers. acting as sole providers. In volume or high-expenditure â¢ Productivity metrics may not accurately reflect addition, to improving the components of health care delivery, the intensity of clinical workload. A 2016 VA audit accuracy of the VAâs such as emergency department and shows that VA providers do not always accurately productivity metrics and urgent care, and determines the code the intensity ofâthat is, the amount of effort efficiency models, we extent to which use and needed to performâclinical procedures or recommended that the VA expenditures differ from expected services. As a result, the VAâs productivity metrics help ensure the accuracy of levels. may not accurately reflect provider productivity, as underlying workload and This testimony addresses (1) differences between providers may represent staffing data by, for example, whether the VAâs clinical coding inaccuracies rather than true productivity developing training for all productivity metrics and efficiency differences. providers on coding clinical models provide complete and â¢ Productivity metrics may not accurately reflect procedures. The VA agreed accurate information on provider providersâ clinical staffing levels. Officials at five in principle with our productivity and VAMC efficiency of the six selected VAMCs we visited reported that recommendations but did not and (2) the VAâs efforts to monitor providers do not always accurately record the provide information on how and improve clinical productivity amount of time they spend performing clinical it plans to make and efficiency. duties, as distinct from other duties. The VAâs improvements. productivity metrics are calculated for providersâ clinical duties only. â¢ Efficiency models may also be adversely affected by inaccurate workload and staffing data. To the extent that the intensity and amount of providersâ clinical workload are inaccurately recorded, some of the VAâs efficiency models examining VAMC use and expenditures may also be inaccurate. Ongoing Efforts This statement summarizes GAOâs As GAO reported in September 2015, VBA has Three areas could benefit Can Be Improved; September 2015 report (GAO-15- made progress in developing and implementing the from increased management Goals Are Needed 582) on (1) the VAâs progress VBMS, with deployment of the initial version of attention: to Promote toward completing the development the system to all of its regional offices as of June â¢ Cost estimating: The Increased User and implementation of the VBMS 2013. Since then, VBA has continued developing program office does not have Satisfaction and (2) the extent to which users and implementing additional system functionality a reliable estimate of the cost (2016) report satisfaction with the system. and enhancements that support the electronic for completing the system. processing of disability compensation claims. As a Without such an estimate,
Title (Year) Purpose of Report Findings Recommendations result, 95 percent of records related to veteransâ VA management and the disability claims are electronic and reside in the departmentâs stakeholders system. However, VBMS is not yet able to fully have a limited view of the support disability and pension claims or appeals systemâs future resource processing. While the Under Secretary for Benefits needs stated in March 2013 that the development of â¢ System availability: VBMS was expected to be completed in 2015, the Although VBA has improved implementation of functionality to fully support its performance for ensuring electronic claims processing has been delayed the system is available to beyond 2015. In addition, VBA has not yet users, it has not established produced a plan that identifies when the system system response time goals. will be completed. Accordingly, holding the VA â¢ System defects: While the management accountable for meeting a time frame program has actively and for demonstrating progress will be difficult. managed system defects, a recent system release included unresolved defects that affected system performance and usersâ experiences. Ongoing GAO (1) assessed the VAâs VBA has made progress in developing and See Ongoing Efforts Can Be Development and progress toward completing the implementing the VBMS, with deployment of the Improved; Goals Are Needed Implementation development and implementation of system to all of its regional offices as of June 2013. to Promote Increased User Can Be Improved; VBMS and (2) determined to what While 95 percent of records related to veteransâ Satisfaction (2016) Goals Are Needed extent users report satisfaction with disability claims are electronic and reside in the to Promote the system. To do so, GAO system, additional capabilities have not yet been Increased User reviewed relevant program completed, such as automation of the steps Satisfaction documentation, administered a associated with a veteranâs request for an increase (2015) survey to a stratified random sample in benefits. Furthermore, VBA has not yet of about 3,500 users, and developed and implemented pension processing interviewed appropriate VA capabilities in VBMS, nor has it articulated when officials. the system will support appeals processing. Improvements This report evaluates (1) the extent VBAâs dual approach for measuring accuracy is Leverage appropriate Could Further to which VBA effectively measures designed to provide additional information to better expertise to help VBA do Enhance Quality and reports the accuracy of its target quality improvement efforts, but its methods each of the following: disability compensation claim and practices lack rigor and transparency, thereby â¢ Weight its accuracy 195
196 Title (Year) Purpose of Report Findings Recommendations Assurance Efforts decisions and (2) whether VBAâs undermining the usefulness and credibility of its estimates to reflect the (2014) other quality assurance activities are measures. By not leveraging a statistician or sample design for reviewed coordinated and effective. GAO otherwise following statistical practices in claims; analyzed VBA claims and STAR developing accuracy estimates, VBA is producing â¢ Determine and report the accuracy data from fiscal year 2013 and relying on inaccurate estimates to make confidence intervals (the most recent fiscal year for important internal management decisions. associated with its reported which complete data are available); Similarly, by using a one-size sampling accuracy estimates; and reviewed relevant federal laws, methodology, VBA is unnecessarily expending â¢ Re-examine its approach to VBA guidance, and other limited resources that could be used elsewhere. The calculating the regional office documents relevant to quality systematic exclusion of redistributed claims and sample size for STAR. assurance activities; and those moved between offices further calls into Take steps to ensure that interviewed VBA staff from question the rigor of its accuracy estimates. Finally, redistributed claims and those headquarters and four VBA regional VBAâs reporting of its two accuracy metrics lacks moved between regional offices (selected to achieve variety sufficient transparency to help members of offices are not in geography, workload, and Congress and other stakeholders fully understand underrepresented in the accuracy rates) as well as veteran the differences and limitations of each and thus STAR sample. service organization officials. may undermine their trust in VBAâs reported â¢ Increase transparency in performance. VBA has enhanced and coordinated explaining how the claim- other aspects of its quality assurance framework, based and issue-based but shortcomings in implementation and evaluation accuracy rates are calculated detract from their overall effectiveness. For as well as their key example, although VBA is disseminating the limitations when publicly results of national STAR reviews and consistency reporting these metrics. studies and local quality review teams (QRTs) are â¢ Review the multiple sources using those results to focus related training or of policy guidance that VBA guidance to claims processing staff, until provides to determine ways centralized guidance is consolidated and to consolidate them. streamlined, staff lack ready access to information â¢ Take steps to ensure that that will help them prevent errors. Moreover, any future upgrades to local absent adequate system capabilities to support local data systems allow QRTs to quality reviews, QRTs are unable to stop incorrect pause the claims process decisions from being finalized, and may not be when errors are detected and aware of error trends that could be mitigated enable QRTs to better track through training or other corrective action. Finally, error trends. although some of its quality assurance activities are â¢ Take additional steps to
Title (Year) Purpose of Report Findings Recommendations relatively new, VBA lacks specific plans to evaluate the effectiveness of evaluate their effectiveness and may miss quality assurance activities to opportunities to further improve or target these identify opportunities to activities to more error-prone areas. In general, improve or better target these unless VBA takes steps to improve the rigor of all activities. its quality assurance methods and practices, VBA may find progress toward achieving its goal of 98 percent accuracy in fiscal year 2015 illusiveâ especially in the face of challenging workloads, limited resources, and expectations of timely claim decisions. Actions Needed to Concerns exist that the VAâs rating The VA initiated a comprehensive effort in 2009 to Conduct focused studies on Address Hurdles scheduleâthe criteria used to revise its disability rating schedule with both various approaches to Facing Program assign degree of work disabilityâis updated medical and earnings information, but it modernize disability benefits Modernization not consistent with changes in faces hurdles with several key aspects. The current and, if necessary, propose (2012) medicine and the labor market. revision effort takes a more comprehensive and relevant legislation. GAO is GAO examined (1) the VAâs empirical approach than the VAâs past efforts. The also making several progress in revising its rating VA has hired full-time staff to revise the rating recommendations to improve schedule with updated medical and scheduleâs medical information and plans to the VAâs capacity to revise economic information and (2) the conduct studies to evaluate veteransâ average loss the rating schedule now and opportunities and challenges of of earnings in todayâs economy. As part of this in the future. These include various policy approaches proposed effort, the VA is considering modifying the rating completing plans for by commissions and others for scheduleâcurrently based largely on the degree of conducting earnings loss updating the VAâs disability medical severityâto include a veteranâs ability to studies and developing a benefits structure. function in the workplace. Moving in this direction written strategy for is more consistent with how experts conceive of implementing revisions to the disability. rating schedule. VA Needs Plan Key questions: (1) Since the Since the issuance of GAOâs 2002 report, the VA Develop a plan, and include it for Assessing issuance of GAOâs 2002 report, has not systematically assessed the consistency of in the VAâs annual Consistency of what actions has the VA taken to regional office decisions on specific impairments. performance plan, that details Decisions (2004) assess the consistency of regional Existing compensation program data have how the VA will: (1) use data office decisions on disability limitations that preclude identifying indications of collected through RBA 2000 compensation claims? (2) To what decision-making inconsistency among regional to identify indications of extent does the VA have program offices. However, the VA is implementing a new possible inconsistencies data that can be used to measure the data collection system that may afford an among regional offices in the 197
198 Title (Year) Purpose of Report Findings Recommendations consistency of decision making opportunity to identify indications of inconsistency award and denial of benefits among regional offices? in the future. 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 Focus on four key areas related to VBAâs problems with large backlogs and long VBA may need to collect and Challenges Facing compensation claims processing: (1) waits for decisions have not yet improved, despite analyze additional case- Disability Claims longstanding performance years of studying these problems. VBAâs new specific data to better Processing (2000) problems, (2) claims-processing quality measurement system shows that nearly one- understand its claims- complexities, (3) challenges to third of decisions are incorrect or have technical or processing problems and improving performance, and (4) procedural errors. Many performance problems better target its corrective VBAâs initiatives to improve stem from the processÊ¼s complexity, which is actions. Furthermore, because performance. growing as the number of service-connected some issues affecting VBAâs disabilities per veteran increases and judicial performance are a function of review requires more procedures and program design, more documentation. Although VBA has initiated a fundamental changes may number of efforts to streamline its claims- have to be made. processing performance, it is unclear how much improvement will be gained.