United States General Accounting Office

GAO Report to the Chairman, Committee on

Veterans’ Affairs, House of

Representatives

July 1997 VA HEALTH CARE

VA Is Adopting

Managed Care

Practices to Better

Manage Physician

Resources

GAO/HEHS-97-87

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-270579 

July 17, 1997

The Honorable Bob Stump

Chairman, Committee on Veterans’ Affairs

House of Representatives

Dear Mr. Chairman:

The Department of Veterans Affairs (VA) is one of the nation’s largest

employers of physicians. In fiscal year 1996, VA’s Veterans Health

Administration (VHA), one of the nation’s largest direct health care delivery

systems, operated 173 hospitals, 398 outpatient clinics, 133 nursing home

units, and 40 domiciliaries.1

 That same year, VA spent $1.7 billion in

salaries and benefits for 10,102 full-time-equivalent (FTE)

physicians—actually, more than 14,000 part- and full-time physicians2

—to

provide medical care to almost 3 million patients, or approximately

10 percent of all veterans.

In light of the pressures on the health care industry in general and on VA in

particular to achieve greater efficiencies as they operate within

ever-tighter budgetary constraints, you asked that we provide information

on what VA is doing to manage its physician resources as well as how

health maintenance organizations (HMO) manage their physician resources.

To obtain this information, we reviewed VA policies and procedures,

interviewed officials at both VA and selected HMOs, and extensively

reviewed the existing literature. We also visited four VA medical

centers—at Houston, Texas; San Francisco, California; Spokane,

Washington; and Togus, Maine. These medical centers represented a

mixture of size; mission; cost per patient treated; and level of affiliation

with medical schools—that is, the size of the patient case workload, the

number of residents in training, and the amount of research conducted

jointly with medical schools. These facilities are not, however, statistically

representative of all VA medical centers. During our site visits, we

interviewed a random sample of physicians and examined all relevant

records, including personnel and performance records for these

physicians, to determine how policies and procedures were applied. We

also interviewed officials at medical schools affiliated with VA medical

1

Domiciliaries provide shelter, food, and necessary medical care on an ambulatory basis to veterans

who are disabled by age or disease but not in need of skilled nursing care or hospitalization.

2

These figures do not include physicians hired on a fee or contract basis, medical residents, or fellows.

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centers and other health care experts. (See app. I for more detail on our

scope and methodology.)

Results in Brief VA is in the midst of making fundamental changes in its health care

delivery system because of budgetary pressures and increasing

competition in the health care industry. Many of these initiatives are

affecting the entire VA health care delivery system; they will also affect

how VA manages physician resources, including identifying the appropriate

number and skill mix of physicians and monitoring productivity and

quality of care provided. These initiatives involve changes in physician

practice patterns and in resource allocation to help ensure effectiveness

and efficiency.

VA is changing physician monitoring by emphasizing standardized

productivity and clinical care outcome measures, which are increasingly

being used in the private sector to monitor the efficiency and effectiveness

of physician performance.3

 In addition, further embracing private sector

managed care practices, VA is changing the way physicians practice by

assigning veterans to a primary care physician, an approach that

emphasizes continuity of care, prevention, and the early diagnosis of

disease and allows VA to better attribute clinical care outcomes to specific

provider performance. VA expects to change physician practice patterns

and improve service delivery efficiencies by distributing health care

funding on the basis of workload rather than according to historic funding

patterns, which perpetuated imbalances in funding, efficiency, and access

to care throughout the VA health care system. VA has introduced a

capitated, patient-based resource allocation system using 22 regional

networks as the basic allocation unit rather than individual medical

facilities, which will result in resource shifts among the networks and

physician staffing reductions in some areas of the country.

VA has not developed a staffing and resource allocation model that

identifies optimal physician staffing levels or the skill mix of physicians

needed to provide health care to eligible veterans, and no agreed-upon

physician workload standards exist either in the private sector or at VA for

most physician specialties, including primary care.

VA faces unique challenges in managing its physician resources. It must

balance multiple congressionally mandated missions, such as training

3

Standardized performance measures include productivity indicators, such as the number of specific

procedures performed, and clinical care outcome indicators, such as level of customer satisfaction and

mortality rates.

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health care professionals, that reduce physicians’ clinical care productivity

relative to that of physicians in private sector HMOs. In addition, VA

performance measurement and allocation systems are hampered by

incomplete and inaccurate data. For example, physician-specific

information is not generally available on cost and utilization. Although VA

is implementing a new cost-based data system, the system will not be fully

operational until fiscal year 1998.

Moreover, accurate estimates of workload, an essential element of

resource allocation, are particularly challenging with a patient population

that is sicker and older than the general population and that moves in and

out of the VA health care system. While HMO patients generally obtain most

or all of their medical care from the HMO, more than half of VA patients

receive part of their care from non-VA providers. To the extent that

veterans reserve VA for their more costly health care, the success of VA’s

physicians in using primary care for prevention and early diagnosis of

disease—key predictors of clinical care outcomes—may be hampered.

Finally, physician productivity is undermined by insufficient clinical space

and support staff as VA makes the transition to providing primary care on

an outpatient basis.

Background In 1930, the Congress established VA, including a system for providing for

the rehabilitation and continuing care of veterans injured during wartime

service. Over the past 65 years, the Congress has expanded VA’s health

care mission beyond direct care for service-connected injuries to include

complete medical care for veterans. In the 1940s and ’50s, the Congress

added medical education and research missions. The purpose of the

medical education mission was to strengthen the quality of care in VA

facilities and to help train the nation’s health care professionals. To

contribute to the nation’s knowledge about disease and disability, the

Secretary of VA is now legislatively required to carry out a program of

medical research in connection with the provision of medical care and

treatment of veterans.4

Many VA medical centers have affiliated with medical schools since 1946,

and today almost 80 percent of VA medical centers are affiliated with one

or more medical schools. Approximately 70 percent of all physicians

employed by VA hold faculty appointments at these medical schools, and

many hold part-time positions at both VA and the affiliated medical

4

In 1982, the Congress added another role for VA by authorizing it to serve as the primary health care

backup to the Department of Defense in the event of war or national emergency.

Page 3 GAO/HEHS-97-87 VA Physician Staffing
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schools. These affiliations are intended to aid in the recruitment of highly

qualified staff to provide VA patient care and to meet VA’s education and

research goals. VA, in return, provides clinical experience at its medical

centers for over 100,000 health profession students from more than 1,000

educational institutions every year. Of these 100,000 students, more than

32,000 are medical residents and about 20,000 are medical students.

VA employs physicians under title 38 of the U.S. Code on both full- and

part-time bases. For those physician services for which demand or the

salary VA is able to offer is insufficient to employ a physician directly, VA

contracts for physician services, often with a doctor associated with an

affiliated medical school.5

 In fiscal year 1993, the latest year for which data

are available on FTE employees for contract and fee-based physician

services, VHA obtained physician services equivalent to the services of

about 19,400 full-time physicians, either directly, as VHA employees, or

through contracts and residencies.6

Physician salaries and benefits have consumed approximately 10 percent

of VHA’s total medical care expenditures since 1985, as shown in figure 1.

In fiscal year 1996, VHA spent $16.6 billion on medical care,7

 26 percent

more than in fiscal year 1985 after adjusting for inflation, while VA

physician salaries and benefits rose 25 percent over the same period.

5

These services are acquired on either an hourly or a procedural basis.

6

Residents are physicians who have completed medical school and are enrolled in a postgraduate

medical education program leading to qualification in a medical specialty or subspecialty.

7

Congressional authorizations for fiscal years 1997 and 1998 cap increases at 4.14 and 3.77 percent.

Page 4 GAO/HEHS-97-87 VA Physician Staffing
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Figure 1: VA Medical Expenditures,

Fiscal Years 1985-96 Dollars in Thousands

0

2000

4000

6000

8000

10000

12000

14000

16000

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

Fiscal Year

Total Medical Expenditures

Physician Salary and Benefits

Under the Veterans’ Health Care Eligibility Reform Act of 1996, all

veterans are eligible to receive comprehensive VA medical care.8

 However,

veterans’ actual receipt of such care depends on a complex priority system

based on the nature of their military service, level of disability, and

income, as resources permit.9

VA Is Changing How It

Manages Physician

Resources

VA is making fundamental changes in how it manages physician resources

as it adopts private sector methods to ensure the efficiency and

effectiveness of its physician workforce. VA, like HMOs, is developing

standardized productivity and clinical care outcome measures to monitor

physician performance. It is also changing the way physicians practice by

moving from providing episodic, specialized care to a patient-based

primary care model, long embraced by HMOs. Furthermore, VA is

implementing a capitated, patient-based resource allocation system to

8

Such medical care is discretionary to the extent that the Congress must pass an annual appropriation

for VHA to expend funds.

9

The Veterans’ Health Care Eligibility Reform Act of 1996, P. L. 104-262, which became law on Oct. 9,

1996, eliminates distinctions in eligibility criteria based on inpatient and outpatient care.

Page 5 GAO/HEHS-97-87 VA Physician Staffing
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provide physicians and others with incentives for providing the most

efficient and effective care. Finally, VA has not developed a staffing and

resource allocation model that identifies the optimal physician staffing

levels, and no agreed-upon physician workload standards exist—including

for primary care—either at VA or in the private sector.

VA, Like HMOs, Is

Developing Standardized

Measures to Monitor

Physician Performance

Both HMOs and VA are increasingly emphasizing the use of performance

measures, such as productivity and clinical outcomes, to manage

physician resources. Productivity measures, for example, count the

number of specific procedures performed or patients treated, while

clinical care outcome measures reflect the results of care, such as level of

customer satisfaction or readmission and mortality rates. HMO officials told

us that increased price competition has forced them to focus on physician

productivity in a new way. VA officials cited budgetary pressures; hiring

restrictions; the deliberations of the President’s 1993 health care reform

task force, which included comprehensive assessment of VHA’s role in the

delivery of the nation’s health care; and increasing competition in the

health care industry as incentives for innovation in this area.

VA and HMO officials told us that because monitoring individual physician

productivity is a new issue for health care providers, few historical data or

standards are available to identify acceptable productivity levels and to set

standards for appropriate physician staffing. For many years, physicians

have predominantly practiced in independent or small group

fee-for-service practices. Physicians’ individual productivity has been

reflected primarily in their personal income, and data have not generally

been collected on their individual productivity. Officials that we

interviewed at the staff model HMOs—HMOs that employ their own

physicians to provide health care to enrollees—also stated that physicians

have generally not been accountable for productivity to others within their

organizations. VA officials reported that they have historically emphasized

holding physicians accountable for working their minimum hours of work

rather than for their individual or collective performance.

VHA’s 1996 publication, Prescription for Change, identifies development of

a monitoring system that tracks performance and provides timely

feedback to health care providers as necessary to VHA’s goal of improving

its effectiveness and efficiency.10 Standardization within VA will permit it to

compare the performance of its facilities and regions. VA’s plans echo HMO

10Kenneth W. Kizer, M.D., M.P.H., Under Secretary for Health, VA, Prescription for Change: The

Guiding Principles and Strategic Objectives Underlying the Transformation of the Veterans Healthcare

System (Washington, D.C.: VA, Mar. 1966).

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officials’ desire to emphasize performance measures that allow

comparison with other national and local private sector measures. VA is

also designing performance measures to allow comparison with current

trends in performance evaluation supported by the Joint Commission on

Accreditation of Healthcare Organizations.

The VA Under Secretary for Health has overall responsibility for

monitoring physicians in VHA. VA medical center directors are responsible

for monitoring physicians at the medical center level, which includes

ensuring accurate time and attendance reporting. In practice, directors

typically depend on the clinical service chiefs—the heads of the different

specialty “departments”—to monitor physician attendance and to ensure

that time cards are accurate. Service chiefs may do this themselves or they

may delegate these duties to the chiefs of the services’ different clinical

sections.

Service chiefs told us that they were placing less emphasis on such

management tools as monitoring physicians’ time and attendance and

emphasizing instead physicians’ productivity and accomplishments during

their work hours, including the outcome of the care provided. Service

chiefs in all four medical centers we visited were individually creating or

adapting automated performance monitoring systems because no central

VA databases provided them with the information they needed. Without

standardized systemwide data, service chiefs had begun individually

collecting and analyzing physician-specific productivity data, such as the

number of procedures performed, number of patients seen, and length of

time patients had to wait for an appointment. The service chiefs generally

saw their individual efforts as temporary. They were enthusiastic about

VA’s implementation of a new systemwide cost-based data collection

system to provide both individually tailored and systemwide data on

physician-specific performance.

Service chiefs were using the information they collected in multiple ways.

A service chief at one medical center reported using productivity

comparisons to convince the medical center leadership council of the

need to move physicians from other services, or specialty areas, into his

service. He also planned to use the data to encourage competition among

primary care teams and to identify efficient and effective practice patterns.

Many of the service chiefs we interviewed had used productivity data to

identify and document physician performance problems. They provided

individual physicians within their service with data on how their

performance compared with that of others to encourage improved

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B-270579 

performance. At all four medical centers we visited, management was

using productivity data in personnel actions involving individual doctors.

Many service chiefs expressed frustration about their inability to identify

appropriate local and national data to use as benchmarks. They had to

identify benchmarks by directly contacting their counterparts in private

sector organizations or by using prior experience in university or private

sector hospitals for comparison purposes.

Both VA and HMO officials emphasized that productivity has to be combined

with analysis of clinical outcomes to ensure the usefulness of performance

measures. Service chiefs and HMO officials we interviewed were still in the

process of defining and measuring productivity and had not yet developed

a system to tie clinical outcomes to performance.

VA Is Shifting Its Focus

From Specialty to Primary

Care

Embracing managed care practices used in the private sector, VA is also

changing how its physicians practice medicine, emphasizing

patient-centered primary care rather than episode-specific specialty care.

HMOs have long been committed to the concept of primary care, which

focuses on the patient and emphasizes preventing illness and diagnosing

the early onset of disease. VA, on the other hand, has historically

emphasized injury- or illness-specific medical care provided by one or

more specialists who treat the patient only for the condition within their

specialty.

VA has now directed that the majority of its patients be assigned to a

primary care physician who is responsible for coordinating all aspects of

the patient’s care, whether on an outpatient or inpatient basis. To ensure

continuity of care, the patient returns to the primary care physician after

any specialist care has been completed. Assigning veterans to the care of

individual physicians allows VA to better attribute clinical care outcomes

to specific provider performance because one physician has greater

responsibility and control over the patient’s care.11 As of February 1997, VA

reported that 53 percent of its patients had been assigned a primary care

provider. This represents 72 percent of all the patients VA has specifically

targeted for primary care: those who have had two or more clinic visits

within the past year.

11In 1993, we reported that assigning patients to primary care providers decreased unnecessary visits.

See VA Health Care: Restructuring Ambulatory Care System Would Improve Services to Veterans

(GAO/HRD-94-4, Oct. 15, 1993).

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VA Struggles to Provide

Primary Care With Oversupply

of Specialists

VA is attempting to provide primary care with a physician workforce that is

predominantly specialist. Overall, about one-quarter of VA’s physicians are

primary care physicians, and about three-quarters are specialists; more

than half of managed care plans’ physicians are typically primary care

physicians.

The four medical centers we visited were using different methods of

restructuring their physician groups to provide primary care using the

specialist physicians currently on staff. For example, the chief of the

medical service at one large facility had organized physicians into two

multispecialty group practices, while at a smaller facility physicians were

divided into four teams. At the large facility, each clinic had a group of

staff physicians representing key specialties: one cardiologist, one renal

specialist, one pulmonologist, and one opthalmologist working side by

side. Each specialist was assigned the primary care of patients whose

major problem lay within his or her area of expertise. The specialist

assumed responsibility for coordinating the total care of the patient, on

both inpatient and outpatient bases. The multispecialty group setting

provided the physician easy access to a variety of other specialists for

informal consultation. The consulting specialist set up a separate

appointment with the patient only when he or she believed the case

warranted special treatment. The chief described the efficiencies in the

following way:

“In the past, we had a cardiology, renal, and pulmonary clinic, each of which was extremely

narrowly focused. All the specialists paid attention only to the problems the patient had

that were in their area of expertise. For example, if you were a cardiologist you took care

of only the heart. If [patients] also had diabetes you referred them to the diabetes clinic for

that. These patients were scattered all over the hospital with multiple providers working

without any communication among them, often providing redundant or conflicting 

care . . . . [Now patients have] one-stop shopping.”

In the smaller facility, 11 of the 13 physicians in the medical service were

divided into three teams, and psychiatrists made up the fourth. Two

physicians, an oncologist and a gastroenterologist, remained outside the

three medical teams, practicing exclusively in their area of specialization.

None of the physicians had a training focus specifically in primary care

areas, such as internal medicine, gerontology, or family medicine.

Service chiefs at the medical centers we visited told us that they planned

to use clinical practice guidelines in assisting the specialists’ transition to

primary care. VA required its regions to adopt a minimum of five nationally

Page 9 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

developed clinical practice guidelines by the end of fiscal year 1996 to

manage resource-intensive chronic diseases, such as major depressive

disorder and ischemic heart disease. Clinical practice guidelines are

systematically developed statements that assist practitioners in making

decisions about appropriate health care for specific clinical conditions.12

Another means of changing the physician skill mix is to eliminate

specialist positions. In March of 1996, VA gave facility management

authority for the first time to reduce title 38 physician staffing levels

through terminations without central office approval and without offering

the physicians the opportunity to move elsewhere in the system. Some of

the service chiefs told us that they anticipated using this authority to

eliminate excess specialist positions, and officials at one of the regions

identified specific specialist positions they planned to eliminate through

the new procedure.

VA Is Attempting to

Increase Physician

Efficiency Through

Changing the Way It

Allocates Funding

VA expects to change physician practice patterns and improve service

delivery efficiencies by distributing health care funding on the basis of

workload rather than using historic funding patterns. VA is implementing a

capitated patient-based resource allocation system designed to increase

incentives for physicians and others to provide the most efficient and

effective care. Changes in the allocation of VA’s health care budget will

have an impact on the distribution of physician resources.

In spite of previous attempts to link funding to the work performed and

the cost to perform it, VA’s distribution of resources has remained almost

exclusively related to the amount that each facility received in the past.13

The Resource Allocation Methodology (RAM) system, begun in 1985, was

discontinued in 1989 because of concerns that it provided facilities with

inappropriate incentives to expand workload beyond resource

constraints.14 The Resource Planning and Management (RPM) system,

begun in 1994, defined workload as patients served rather than procedures

performed and was, therefore, less susceptible to attempts to gain

resources through inappropriate performance or recording of workload.

The RPM system did not, however, encourage cooperation among facilities.

12For information on how managed care plans use practice guidelines, see Practice Guidelines:

Managed Care Plans Customize Guidelines to Meet Local Interests (GAO/HEHS-96-95, May 30, 1996).

13See Veterans’ Health Care: Facilities’ Resource Allocations Could Be More Equitable

(GAO/HEHS-96-48, Feb. 7, 1996) and VA Health Care: Resource Allocation Methodology Has Little

Impact on Medical Centers’ Budgets (GAO/HRD-89-93, Aug. 18, 1989).

14For example, under RAM, a facility could get more workload credit for hospitalizing a patient than if

the same care was provided on an outpatient basis.

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In addition, VHA officials told us the RAM and RPM systems were too

complex, requiring so many computer algorithms that few VHA officials

understood how the allocation systems worked. The RPM system was used

to make only minimal changes to facility budgets, on average less than

1 percent.

In order to encourage decisions affecting the delivery of patient care

services to be based on collaboration among VA facilities rather than on

the interests of the individual facility, VA decided to distribute funds on a

regional rather than a medical facility basis. By June 1996, VA had

incorporated its 159 independent medical centers into 22 veterans

integrated service networks (VISN) that report directly to the Office of the

Under Secretary for Health.15 These networks are designed to replace the

individual facilities as both the basic planning and budgetary units.

According to the Under Secretary for Health:

“The hospital will remain an important, albeit less central, component of a larger, more

coordinated community-based network of care . . . . The basic concept of an integrated

health care organization is that it is one that will be accountable for providing a

coordinated range of physician, hospital, and other medical care services for a defined

population, and generally for a fixed amount. The assumption is that it will be easier and

more efficient to provide for all the needs of the population if all the pieces of the health

care system needed to provide the care are integrated into, and under the control of, a

single entity . . . . Under the VISN model, health care will be provided through strategic

alliances among VA medical centers, clinics and other sites; contractual arrangements with

private providers; sharing agreements with other government providers; and other such

relationships.”16

This restructuring was also intended to change the relationship between

the central office and the regions. In recognition of regional differences in

practice patterns, patient characteristics, and geography, VA is moving

more of the daily operational decisions and oversight to networks, leaving

the central office to focus more on policy development and leadership.

Each network will determine how funds are distributed to the medical

facilities within its geographic region. Individual business plans drafted by

the 22 networks propose a wide variety of distribution strategies.

15Until this reorganization, all 173 VA hospitals and most outpatient clinics, nursing homes, and

domiciliaries were part of one of the 159 medical centers. Facilities within the medical centers may

have been spread over a wide geographic area, but they were still managed by the medical center

director.

16See Kenneth W. Kizer, M.D., M.P.H., Under Secretary for Health, VA, Vision for Change: A Plan to

Restructure the Veterans Health Administration (Washington, D.C.: VA, Mar. 1995).

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Although the networks were not fully operational until June 1996, during

our May 1996 visit to one small medical center, we were told about a

strategic alliance between medical centers in that network that was

intended to increase efficient and effective use of physician resources.

This network covers an unusually large and geographically rugged area

with harsh winters, which prevents travel among some of its medical

facilities, except by air. The network had initiated a pilot program to test

the feasibility of flying a cardiologist from a large medical center to a small

medical center to provide pre- and postoperative care for patients needing

heart surgery, which was not available at the smaller facility. Importing a

cardiologist eliminated the need for VA to fly veterans back and forth

several times for preoperative consultation and follow-up care. As a result,

VA officials saw potential cost savings, increased physician productivity at

the smaller medical center by eliminating administrative tasks associated

with moving sick veterans, and improved quality of care. Allocating

resources to the network rather than to the individual medical facilities

provides incentive for changes of this nature.

In April 1997, VA began implementing a capitated, patient-based resource

allocation process, the Veterans Equitable Resource Allocation system for

distributing funds to the networks. Capitation is a risk-sharing

reimbursement method used in the private sector whereby providers in a

plan’s network receive fixed periodic payments for health services

provided to plan members. Capitated fees are set by contract between

prepaid managed care plans (typically HMOs) and providers to be paid on a

per-person basis, usually with adjustments for age, sex, and family size,

regardless of the amount of services provided or costs incurred.

Under the new allocation system, each network will be able to allocate

funds to its facilities as it deems appropriate, which is expected to result in

physician staffing reductions in some areas of the country. Moreover, in

anticipation of potential funding reductions, some networks have already

begun to reduce their physician workforce by eliminating part-time and

temporary physicians, voluntary separations, and terminating some

full-time physicians. These networks expect still further reductions within

the next few years.

VA Has Not Developed a

Way to Identify Optimal

Physician Staffing Levels

VA has not developed a staffing and resource allocation model that

identifies optimal physician staffing levels or the skill mix of physicians

needed to provide health care to eligible veterans, and no agreed-upon

physician workload standards exist within either the private sector or VA

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for most physician specialties, including primary care. VA and the staff

model HMOs we visited are struggling to determine suitable physician

staffing levels and to distribute their physician resources efficiently,

effectively, and equitably given the diversity of health care facility

missions, patients, and community resources. HMO officials reported that

they had not yet successfully identified a method for staffing physicians

but did not believe that a purely quantitative approach was appropriate.

Officials of accreditation bodies stated that physician workload standards

were not used because there were none that were appropriate for the

variety of medical care providers and settings.

In 1987, VA contracted with the Institute of Medicine (IOM), an arm of the

National Academy of Sciences, to create a mathematical/statistical model

to estimate the appropriate physician staffing levels for individual VA

medical centers. VA officials told us that they did not adopt the IOM model,

published in 1991, because it was too complicated for physicians and

managers to understand. In addition, they did not trust the reliability of the

data the model required.17 IOM noted that VA had published staffing

guidelines for most nonphysician health care provider categories. IOM

acknowledged, however, that complexities such as clinical, economic,

statistical, administrative, and political issues prevented VA from

establishing similar guidelines for physicians.

VA Faces Unique

Challenges in

Managing Physician

Resources

As it moves toward managed care, VA differs from private sector managed

care organizations in ways that present unique challenges—particularly in

managing physician resources. First, managing physician workload is

complicated by the need to balance VA’s primary patient care mission with

its education and research missions. In addition, automated performance

management and resource allocation systems that could assist in

managing the physician workload lack complete and accurate data. Third,

providing health care to an older and sicker patient population that moves

in and out of the system complicates estimation of physician workload.

Finally, VA physician productivity is undermined by insufficient support

staff and clinical space.

The changes VA is making may improve the efficiency of VA physicians, but

they may also, in the short term, increase the total workload. One VA

medical center service chief noted the following:

17The VA Inspector General reported in September 1995 that VA medical centers still do not have a

physician staffing methodology that would help them determine the number and type of physician

resources needed. See VA Inspector General, Audit of VHA Resource Allocation Issues: Physician

Staffing Levels, 5R8-A19-113 (Washington, D.C.: VA, Sept. 29, 1995).

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“There are efficiencies in these changes, particularly to the extent that primary care

physicians can reduce the number of clinic visits required for individual patients and to the

extent that expanded outpatient services can more efficiently provide care that was

previously administered on the hospital wards. It is not at all clear, however, that workload

will decrease because VA will now provide a service, comprehensive care, that was

previously not available to most veterans. Moreover, to the extent that this service attracts

more veterans to VA, efficiencies in the care of individual patients will be offset by a rise in

the total number of patients. Also, patients who currently receive part of their care outside

VA, about 40 percent of veterans who come to VA, may increase their care at VA, especially

as charges elsewhere rise.”

VA Faces Difficulty

Balancing Multiple

Missions

Unlike HMOs, VA faces the difficult task of balancing its primary focus,

providing clinical care, with its congressional mandate to contribute to the

education of the nation’s health care practitioners and perform medical

research. In particular, VA’s attempts to hold physicians accountable for

productivity and to move specialists into primary care have raised

concerns among VA physicians that their research and teaching activities

may be compromised.

In Prescription for Change, VA’s Under Secretary for Health set forth 32

guiding principles for changing VA, including the idea that “education and

research activities should be held accountable to, and managed with,

performance expectations and outcome measures in the same manner as

clinical care.”18 However, VA medical center officials told us that they are

struggling with the specifics of how to accomplish this. Significantly more

effort has been made by both the public and private sectors to measure

productivity and outcomes for patient care than for teaching and research.

One result is that VA medical centers and physicians who perform a

significant amount of research or teaching may not compare favorably

with the private sector on patient care productivity measures, such as

number of patients seen or cost per patient.

Medical center officials told us that VA’s central office had established a

guideline that a maximum of 25 percent of VA physician resources be

devoted to research. Officials at the medical centers and networks,

however, told us that they were uncertain as to how to interpret the

guideline. As a result, they interpreted the guideline in different ways. For

example, one of the two highly affiliated centers—that is, one of the

centers with a large patient caseload, a large number of residents in

training, and significant research activity—interpreted the guideline to

18Kizer, Prescription for Change, pp. 7-56.

Page 14 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

mean 25 percent of physician resources overall, while the other applied

the guideline to each individual physician.

Applying this guideline is further complicated by the difficulty of

separating teaching and research activities from patient care. For example,

at the two medical centers discussed, both service chiefs and individual

physicians provided detailed information about their professional

activities that demonstrated that the majority of the physicians’ patient

care time was spent with medical or other health care students. Many of

the physicians involved in research reported a similar phenomenon. For

example, as part of his participation in acquired immunodeficiency

syndrome (AIDS) research, a specialist in infectious disease reported that

most patient encounters were included as part of his participation in

clinical trials undertaken for pharmaceutical companies or the National

Institutes of Health. He was not able to estimate the extent to which

research requirements reduced his clinical productivity. He did, however,

assert that participation in the research allowed him to provide veterans

infected with the human immunodeficiency virus (HIV) with the latest

drugs, which were not yet available on the market. He estimated the drug

savings alone at thousands of dollars per year, per patient.

The chief of the medical service at one affiliated medical center stated

that:

“Our success in expanding outpatient services has come partly at the expense of our

academic mission, particularly in the subspecialties . . . . Medical service . . . has adopted

the policy that faculty who commit a substantial portion of their time to research should be

paid in part by VA and in part by grant support. This increases the direct clinical

productivity per FTE employee, but it threatens the research mission . . . . Some of our best

physician-scientists, therefore, are leaving or actively looking elsewhere.”

Individual physicians reported that their primary care responsibilities and

the increased emphasis on patient care productivity were limiting their

ability to invest in the time-consuming process of obtaining research

grants. Some physicians told us that concerns about cutbacks in research

undermined their commitment to VA, because they had accepted lower

salaries than those offered in the private sector for the unique opportunity

to pursue both research and patient care. For example, one physician

stated that he came to VA from Harvard Medical School so he could do

research.

Page 15 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

The chief of medicine of another medical center cited as a casualty of this

emphasis the departure of a physician within the past year who had spent

5 years as a clinical investigator:

“In part because we are not able to provide him with a [full-time position], he is leaving to

assume a position at . . ., taking with him not only his own expertise but also that of four

junior faculty, all of whom are paid in full by their research support and all of whom have

significant clinical duties. He also takes over half a million dollars in research support . . . .”

Service chiefs expressed the same concerns about maintaining their

teaching mission. For example, a service chief at a highly affiliated facility

reported that the service is no longer accepting medical students because

of severe staff shortages.

While managing physician resources for multiple missions was not a key

issue for the HMOs we visited, officials at the two affiliated medical schools

we visited reported struggles similar to those reported by VA. School

officials emphasized the increased price pressure from managed care as

driving a new emphasis on physician productivity in all missions. In

response to this pressure, one of the schools had developed an

outcome-based system for managing physician resources that included

both teaching and research, which it planned to market as the first of its

kind.

VA Lacks Appropriate Data

Necessary to Manage

Physician Workload

VA’s automated performance measurement and resource allocation

systems lack complete and accurate data. According to health care

experts, comparing the costs of providing health care requires data that

incorporate severity of illness and quality of care. In April 1995, we

reported that VA management information systems were not able to

produce reliable cost and utilization data.19 Without this type of data, VA

cannot determine when to contract for services rather than provide them

directly or set prices for services sold to other health plans that are

adequate to recover its costs. Major improvements in both the quality of

VA’s services and the efficiency with which they are provided depend on

the ability of VA managers to obtain the right information at the right time.

The medical director of one medical center we visited stated that:

“VA has experienced problems with its information system. The existing information system

is good for the use of the past but it is not good for measuring productivity. For example,

managers cannot know how productive a program or its employees are . . . .These data sets

19Barriers to VA Managed Care (GAO/HEHS-95-84R, Apr. 20, 1995).

Page 16 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

can be produced separately from the system, but the two [number of procedures and

physicians] cannot be merged for managers to use in measuring productivity.”

The chief of medical services at a medical center said that:

“VA does not capture a variety of procedures performed, such as cardiac catheterization, so

I collect this information myself. VA does not capture this information in any significant way

. . . . In the past, this procedural information was collected, recorded, and sent to be coded

but many procedures were missed. Some of the data is incredibly inaccurate, such as

inpatient procedures.”

VA is in the process of implementing a cost-based medical information

system—the Decision Support System (DSS)—which is currently in use in

the private sector. DSS has provided hospitals in the private sector with

improved data on patterns of patient care and the cost of providing health

care services. Such information is equivalent to data describing the clinical

services that are billed to insurance companies in the private sector.

However, we previously found that the VA service-specific and cost-related

information that DSS requires to compute the service cost per patient was

incomplete, inaccurate, or inconsistent.20

DSS has the potential to provide VA with provider-specific clinical cost and

productivity information not currently available on a systemwide basis. In

using DSS to combine clinical and financial information from the billing and

accounting systems, VA could, among other things, compare costs incurred

for the services of different physicians and for surgery performed at

different locations; evaluate patient outcomes; and perform analyses on

ways to increase the quality of service, reduce costs, or appropriately price

excess resources offered for sale. DSS can also facilitate a comparison of

patient care with predefined health care standards.

The four medical centers we visited were in different phases of DSS

implementation, from the planning phase to the data analysis phase.

Although VA currently estimates that DSS will not be fully implemented

until fiscal year 1998, one of the medical centers we visited had recently

used the system to make a resource allocation decision. Using cost data, it

had projected dollar savings from purchasing a piece of equipment rather

than hiring an additional physician.

Service chiefs at the facilities we visited told us that successful

implementation of DSS is essential for the appropriate management of

20See VA Health Care Delivery: Top Management Leadership Critical to Success of Decision Support

System (GAO/AIMD-95-182, Sept. 29, 1995).

Page 17 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

physician resources. For example, the chief of psychiatry at one facility

stated that:

“I would like to have the data system generate information more easily. For example, when

I ask for a breakdown of all the night and weekend calls for ultrasound, [computerized

tomography] and [magnetic resonance], the chief technician is counting cases and

generating this information manually. This information is not generated automatically and

[the task] is labor intensive because information is pulled from the [Decentralized Hospital

Computer Program] system. DSS will provide this information.”

Another service chief stated that:

“The VA system created 20 years ago is not sufficient . . . now. Improvement to the data in

the reporting system is in process, but it is slow. The implementation of DSS will be great;

but it is going to take about 3 years to get it up and running. However, once this system is

working, it will make a difference in getting reports.”

While DSS can provide data on patterns of care and patient outcomes as

well as their resource and cost implications, the ultimate usefulness of the

system will depend not on the software but on the completeness and

accuracy of the data going into the system.

VA Patient Eligibility Rules

and Patient Mix Create

Difficulty in Estimating

Physician Workload

Estimating workload is much more difficult in the VA system than in the

private sector because eligibility for VA care is based on circumstances that

may change, while a person’s eligibility under a private health insurance

policy is secure for the duration of the policy. Eligibility for VA health care

is determined by factors such as veterans’ income, the existence or degree

of service-connected disability, and the availability of resources at

individual VA facilities. As a result, a veteran may be eligible for care from

a VA facility at one time but be denied care at another time because of a

change in the veteran’s income, the veteran’s disability status, or the

availability of resources in the geographic area where the veteran seeks

care.

Under the new Veterans’ Health Care Eligibility Reform Act, all veterans

have basic eligibility for comprehensive care. Veterans with

service-connected disabilities rated at 50 percent or

higher—approximately 465,000, or fewer than 2 percent of all

veterans—are automatically eligible for a complete continuum of care. All

veterans are eligible for treatment of service-connected illnesses and

injuries. As of October 1, 1998, veterans with less than 50-percent

Page 18 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

service-connected disability will be eligible for the full continuum of care

only if enrolled in VA’s health care delivery system. Veterans will be

enrolled on the basis of the availability of resources and a complex

priority system that considers level of disability, income, and the nature of

military service.

Prior to the passage of the Veterans’ Health Care Eligibility Reform Act,

veterans’ eligibility for comprehensive outpatient care—the focus of

managed care—was more restrictive than for inpatient care. The new law

eliminated the distinctions between inpatient and outpatient care while

requiring VA to establish a patient enrollment system. Enrollment is

permitted on the basis of legislative priorities up to the number of veterans

VA can accommodate within authorized appropriations.

It is not clear how much VA’s new enrollment system will clarify veterans’

eligibility for care and, hence, facilitate estimating physicians’ workload.

Veterans’ priority for enrollment can still change as level of disability and

income change, and their eligibility can vary with changes in the

definitions and diagnoses of service-connected disabilities. In addition,

conditions may still be treated in isolation for those patients who do not

enroll but who have service-connected conditions, a circumstance that

could limit treatment effectiveness. VA officials told us that veterans who

enroll in one network will be able to obtain care in all networks, but

officials have yet to determine how they will shift resources to

accommodate patient shifts among networks.

VA’s new enrollment system will enable VA to more accurately track the

veterans it serves. However, translating veterans served into estimates of

physician workload will be complicated by the fact that many veterans

receive a significant amount of their care at non-VA facilities. A 1992 VA

survey of veterans showed that almost half the veterans who received care

in VA facilities also received care elsewhere. Once in the VA system,

veterans are generally offered a broader range of services with fewer

limitations and less cost sharing than are available under other public or

private health benefit programs. This suggests that out-of-pocket costs

may influence veterans’ decisions to use VA for health care services even

when they have other options. The extent to which veterans continue to

choose VA facilities for their care may be affected by changes in the

economy or in the health care environment.

Page 19 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

VA Has Insufficient

Outpatient Clinic Space

and Support Staff to

Effectively Use Physician

Resources

VA physician efficiency in providing primary and outpatient care is

hampered by space and resource limitations. Although some VA hospitals

are relatively new and some have been updated, many present structural

barriers, such as inadequate clinic space, to the patient care changes VA is

initiating. At the VA primary care clinics we visited, physicians expressed

concern that limited space significantly reduced the number of patients

they could see. Some of the clinics had only one examination room for

each doctor, while managed care organizations require three to four rooms

per physician. The physicians also expressed concern about the

inadequate number of support staff, such as nurses, nursing assistants, and

secretaries, who could provide valuable assistance in the areas of patient

triage, patient preparation, and record retrieval. Without sufficient support

staff, physicians must perform these tasks themselves, which limits their

effectiveness and efficiency in providing care. Several of the service chiefs

at the two highly affiliated medical centers we visited commented on this

issue. One stated:

“Physician productivity is affected by the quality of the staff that supports the doctor. For

example, VA has not always had the ability to hire well-qualified secretaries because of the

limited pay. In addition, most doctors would be more efficient if they had more nurses to

prepare patients in the clinic area. Many of the VA patients are disabled and need assistance

to dress and undress and get to the examining room. The doctors end up assisting with that

when there are not enough nurses.”

Another service chief commented:

“Waiting time in the outpatient service would improve if there were more support services,

such as nurses, technicians, and medical clerks. Because of personnel shortages,

physicians spend time doing tasks other than direct patient care, such as answering

telephones . . . . An increase in support resources could reduce the turnaround time for

laboratory and other tests.”

Another chief stated:

“I see the need for more support staff because physicians spend time pulling records while

trying to see patients. There are not enough staff in medical administration service to help

physicians get the information they need.”

Another key to effective use of primary care physician resources is

overcoming barriers to patient access. VA lacks the outpatient primary care

network common in private sector managed care plans that is needed to

maximize the potential for primary care to increase physician efficiency

Page 20 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

and effectiveness. VA does not provide veterans access to outpatient care

that is comparable to the access they would have under other public or

private health benefit programs. The geographic inaccessibility of VA

facilities for many veterans may prevent them from seeking care or

keeping clinic appointments before a medical crisis occurs. Frequently,

veterans must travel long distances for outpatient care, while beneficiaries

under other public and private programs generally have access to a broad

range of providers within a few miles of their homes. Forty-four percent of

veterans who use VA live more than 25 miles from the facilities providing

acute medical and surgical care, and 32 percent live more than 25 miles

from outpatient clinics that provide such services. Veterans’ use of VA

health care services declines significantly as distance between veterans

and VA facilities increases.21

In February 1995, VA began encouraging its hospitals to consider

establishing community-based outpatient clinics, which may be

VA-operated clinics or VA-funded or -reimbursed private clinics. VHA

established a general goal of providing access points within 30 minutes of

veterans’ residences.

All four medical centers we visited were taking additional steps to improve

patients’ access to physicians. For example, medical centers were

assigning physicians to evening and weekend clinics, sending physicians in

mobile clinics to treat veterans as far as 200 miles from VA medical centers,

using physician assistants for telephone triage and consultation programs,

and experimenting with telemedicine. One of the medical centers we

visited was exploring the use of videoconferencing to enable medical

center specialists such as psychiatrists to more easily reach patients at

remote clinics. Another facility was using telemedicine to allow

radiologists to read films from other clinics and medical facilities in their

areas.

Conclusion VA is in the midst of fundamental systemwide changes in both

administration of funds and delivery of care that, when completed, will

have the potential to improve the efficiency and effectiveness of VA’s use

of its physicians. Success will depend on VA’s implementation of a

resource allocation system that links resources to workload while

recognizing regional and facility differences, such as geography and

mission. Performance measures must reflect the full range of physician

21See VA Health Care: Improving Veterans’ Access Poses Financial and Mission-Related Challenges

(GAO/HEHS-97-7, Oct. 25, 1996).

Page 21 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

activities and VA’s service to a unique patient population. The resource

allocation and performance measurement systems will require

standardized and accurate data not currently available.

As VA adopts managed care practices like those of private sector HMOs, it

must balance increased clinical productivity with quality of care. For

example, the quality of primary care provided by physicians trained and

experienced in other specialties must be closely monitored. Unlike HMOs,

VA must also maintain equity of access and fulfill its congressionally

mandated education and research missions. In addition, VA serves a

population with different health care needs and access to care

requirements that complicate VA’s efforts to manage care and to use

private sector HMOs as a model. Although VA’s new allocation system will

result in a shift of health care resources from one network to another, the

distribution of resources within the networks will have the greatest impact

on physician staffing levels. Refinement of VA data systems will be critical

for all networks to determine the appropriate number and skill mix of

physicians needed to deliver health care to eligible veterans.

Agency Comments

and Our Evaluation

VA’s Under Secretary for Health, the head of VHA, reviewed a draft of this

report and said that it was generally a fair and balanced presentation of

the issues influencing management of physician resources in both VA and

private sector HMOs. In addition, he noted that the report accurately

characterized the challenges VA faces as it attempts to satisfy

congressionally mandated requirements while moving from a

hospital-based specialty care system to a managed care system

emphasizing primary, outpatient-based care.

The Under Secretary for Health also stated that we should include more

specific descriptions of VA’s specialist retraining programs and trends in

private sector HMOs to address the ratio imbalance between primary care

and specialist clinicians. Our report presents the views of medical center

officials we met with during our review regarding their plans to address

the imbalance between primary care and specialist clinicians in their

locations. However, when we asked for more specific information

regarding specialist retraining programs, VA provided only two other

locations where such retraining had been initiated.

The Under Secretary also suggested that we consider including

information on studies VA has under way on the trending and analysis of

the results of treatment protocols using DSS cost and workload data. While

Page 22 GAO/HEHS-97-87 VA Physician Staffing
B-270579 

such a discussion would provide an indication of the specific type of

information VA is developing, we believe that we have adequately

discussed VA’s efforts to implement DSS and the various potential uses of

this information.

In addition, VA’s Under Secretary offered technical comments on our draft

report, which we incorporated as appropriate. The complete text of VA’s

comments appears in appendix II.

We are sending copies of this report to the appropriate congressional

committees and other interested parties. We will also make copies

available to others upon request.

This work was performed under the direction of George Poindexter,

Assistant Director, who may be reached at (202) 512-7213 if you or your

staff have questions concerning this report. Other major contributors

include Leonard Hamilton, Lise Levie, and Janice Raynor.

Sincerely yours,

Stephen P. Backhus

Director, Veterans’ Affairs

 and Military Health Care Issues

Page 23 GAO/HEHS-97-87 VA Physician Staffing
Contents

Letter 1

Appendix I 

Scope and

Methodology

26

Appendix II 

Comments From the

Department of

Veterans Affairs

28

Related GAO Products 32

Table Table I.1: Selection Criteria for the Medical Centers We Visited 26

Figure Figure 1: VA Medical Expenditures, Fiscal Years 1985-96 5

Abbreviations

AIDS acquired immunodeficiency syndrome

DSS Decision Support System

FTE full-time-equivalent

HIV human immunodeficiency virus

HMO health maintenance organization

IOM Institute of Medicine

RAM resource allocation methodology

RPM resource planning and management

VA Department of Veterans Affairs

VHA Veterans Health Administration

VISN veterans integrated service network

Page 24 GAO/HEHS-97-87 VA Physician Staffing
Page 25 GAO/HEHS-97-87 VA Physician Staffing
Appendix I 

Scope and Methodology

To obtain information on what VA is doing to manage its physician

resources, we interviewed VA central office and field officials and

representatives of VA’s physician association, reviewed VA documentation

on physician staffing, and conducted a literature search on this issue. We

interviewed VA officials in the offices of the Under Secretary for Health,

Academic Affiliations, Policy, Planning and Performance, Research and

Development, and Patient Care Services as well as officials in the Seattle

and Chicago offices of the Inspector General. We also interviewed VA

staffing experts at the Boston Development Center and the Management

Science Group in the Boston, Massachusetts, area. In addition, we

discussed physician staffing issues with the staff at medical centers in San

Francisco, California; Togus, Maine; Houston, Texas; and Spokane,

Washington, along with the network officials associated with the selected

medical centers’ networks. We selected these four medical centers on the

bases of level of affiliation with a medical school and cost per patient

treated.22 We also considered geographic diversity in making our

selections. Table I.1 shows how the medical centers we selected met our

criteria.

Table I.1: Selection Criteria for the

Medical Centers We Visited

Level of affiliation

High cost per patient

treated

Low cost per patient

treated

High San Francisco, California Houston, Texas

Limited or none Togus, Maine Spokane, Washington

At the medical centers, we discussed with officials their methods of

determining staffing needs and reallocating staff on the basis of those

needs as well as their system to monitor physician performance and

account for physicians’ time. We also looked at medical center personnel

documentation on selected physicians. Our visits to these sites resulted in

interviews with about 100 VA staff and private sector officials. But, because

of the limited number of VA sites visited and the unique characteristics of

each, we could not generalize their individual experiences to VA as a

whole.

To determine what HMOs are doing to manage physician resources, we

talked with officials of staff and group model HMOs,23 officials at VA medical

centers affiliated with medical schools, and experts on VA and private

22These factors were identified and the medical centers categorized in Office of the Inspector General,

VA, Audit of Veterans Health Administration Resource Allocation Issues: Physician Staffing Levels,

report no. 5R8-A19-113 (Washington, D.C.: VA, Sept. 29, 1995).

23Staff model HMOs employ their own physicians to provide health care to enrollees; group model

HMOs contract with a group of physicians to provide health care services.

Page 26 GAO/HEHS-97-87 VA Physician Staffing
Appendix I 

Scope and Methodology

sector health care. We interviewed officials with the Group Health

Cooperative of Puget Sound in Seattle, Washington; Harvard Pilgrim

(formerly Harvard Community) in Boston, Massachusetts; and Unified

Medical Group Association and MedPartners Mullikin in Long Beach,

California. We also interviewed officials at the Baylor College of Medicine

in Houston, Texas, and the University of California at San Francisco as

well as health care experts at the Joint Commission on Accreditation of

Healthcare Organizations in Chicago, Illinois.

In addition, we interviewed officials at the National Institutes of Health in

Bethesda, Maryland, to better understand VA’s research mission as it

relates to the missions of patient care and teaching. We did our work

between March 1996 and February 1997 in accordance with generally

accepted government auditing standards.

Page 27 GAO/HEHS-97-87 VA Physician Staffing
Appendix II 

Comments From the Department of

Veterans Affairs

Page 28 GAO/HEHS-97-87 VA Physician Staffing
Appendix II 

Comments From the Department of

Veterans Affairs

Page 29 GAO/HEHS-97-87 VA Physician Staffing
Page 30 GAO/HEHS-97-87 VA Physician Staffing
Page 31 GAO/HEHS-97-87 VA Physician Staffing
Related GAO Products

VA Health Care: Improving Veterans’ Access Poses Financial and

Mission-Related Challenges (GAO/HEHS-97-7, Oct. 25, 1996).

VA Health Care: Issues Affecting Eligibility Reform Efforts (GAO/HEHS-96-160,

Sept. 11, 1996).

Veterans’ Health Care: Challenges for the Future (GAO/T-HEHS-96-172, June 27,

1996).

Practice Guidelines: Managed Care Plans Customize Guidelines to Meet

Local Interests (GAO/HEHS-96-95, May 30, 1996).

VA Health Care: Opportunities to Increase Efficiency and Reduce Resource

Needs (GAO/T-HEHS-96-99, Mar. 8, 1996).

Veterans’ Health Care: Facilities’ Resource Allocations Could Be More

Equitable (GAO/HEHS-96-48, Feb. 7, 1996).

VA Health Care: Exploring Options to Improve Veterans’ Access to VA

Facilities (GAO/HEHS-96-52, Feb. 6, 1996).

VA Health Care: How Distance From VA Facilities Affects Veterans’ Use of

VA Services (GAO/HEHS-96-31, Dec. 20, 1995).

VA Health Care Delivery: Top Management Leadership Critical to Success

of Decision Support System (GAO/AIMD-95-182, Sept. 29, 1995).

VA Health Care: Challenges and Options for the Future (GAO/T-HEHS-95-147,

May 9, 1995).

Barriers to VA Managed Care (GAO/HEHS-95-84R, Apr. 20, 1995).

Veterans’ Health Care: Efforts to Make VA Competitive May Create

Significant Risks (GAO/T-HEHS-94-197, June 29, 1994).

VA Health Care: Restructuring Ambulatory Care System Would Improve

Services to Veterans (GAO/HRD-94-4, Oct. 15, 1993).

VA Health Care: Resource Allocation Methodology Has Little Impact on

Medical Centers’ Budgets (GAO/HRD-89-93, Aug. 18, 1989).

(101483) Page 32 GAO/HEHS-97-87 VA Physician Staffing
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