VA HEALTH CARE

Actions Needed to 

Improve Oversight of 

Community-Based 

Outpatient Clinics

Report to Congressional Requesters

April 2018

GAO-18-375

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-375, a report to 

congressional requesters

April 2018

VA HEALTH CARE

Actions Needed to Improve Oversight of CommunityBased Outpatient Clinics

What GAO Found

Community-based outpatient clinics (CBOC) are an important part of the 

Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) 

health care delivery system. These clinics are geographically separate from VA 

medical centers (VAMC) and provide outpatient services, including primary care

and mental health care. GAO found weaknesses in VHA’s oversight of CBOCs:

• Incomplete policy implementation. VHA has not implemented certain 

CBOC oversight requirements as outlined in its policy. Specifically, VHA has 

not developed guidelines for monitoring the quality and comprehensiveness 

of care in CBOCs and officials said they have no plans to do so. Officials told 

GAO they believe the requirement was met as part of their regular oversight 

of Veterans Integrated Service Networks (VISN)—regional networks 

responsible for oversight of VAMCs and CBOCs. However, VHA may miss 

CBOC performance problems that are not identifiable in VISN-level data. 

Further, although policy requires VHA central office officials to review CBOC 

performance as part of quarterly VISN performance reviews, officials said 

they do not specifically do so unless the VISN identifies a problem. Officials 

from three of the four VISNs in GAO’s review said they largely delegate 

CBOC oversight to VAMCs, and do not separately review clinic performance 

unless a VAMC identifies a problem.

• An inaccurate and incomplete CBOC Report. VHA’s CBOC Report is 

prepared by VHA central office and distributed to VISNs and VAMCs 

quarterly and at year-end. The CBOC Report could be useful to compare

clinical quality of care between VHA-operated and contracted CBOCs, but it

is inaccurate and incomplete. Specifically, VHA officials have used their 

judgment to classify certain sites as CBOCs in the report, rather than use the 

official classifications in policy. GAO found that 22 percent of sites were 

incorrectly classified as CBOCs when they were other types of sites, 

including VAMCs. As a result, the report is of limited usefulness to VHA as 

an oversight tool.

• Lack of guidance or training on the CBOC Report. VHA central office 

officials do not provide guidance or training specific to understanding the 

CBOC Report to assist VISNs and VAMCs in their oversight of CBOCs. GAO 

found that in several places in the report, shorthand text and acronyms were 

used, but not defined. In addition, several VISN and VAMC officials stated 

that guidance or training would be helpful. 

• No requirement to use the CBOC Report. VHA officials told GAO that 

VAMCs and VISNs are expected to use the CBOC Report as an oversight 

tool, but GAO found that VHA lacks a requirement that they do so. Officials 

from three of the four VISNs and three of the four VAMCs in GAO’s review

were not using the report. 

These weaknesses potentially lead to inconsistent oversight and create a risk 

that VHA is not providing one standard of care that is of high quality to veterans 

across VHA-operated and contracted CBOCs.

View GAO-18-375. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov

Why GAO Did This Study

In fiscal year 2016, VHA’s 733 CBOCs 

provided care to more than 3 million 

veterans at a cost of $5.3 billion. 

Although most of these clinics are 

VHA-owned and -operated, 101 are 

operated through contracts with nonVHA organizations. VHA policy states 

that CBOCs, whether VHA-operated or 

contracted, must provide one standard 

of care that is of high quality.

GAO was asked to review VHA’s use 

of contracts to carry out core functions. 

This report examines, among other 

issues, the extent to which VHA 

oversees CBOC operations.

To conduct this work, GAO reviewed 

VHA’s policies and CBOC Report.

GAO also interviewed officials from 

VHA’s central office and from a 

nongeneralizable sample of eight 

CBOCs and their four respective 

VAMCs and VISNs. The CBOCs were 

selected for variation in factors such as 

contract status and geographic area.

What GAO Recommends

GAO recommends that VHA (1)

implement oversight requirements that 

align with existing policy; (2) establish 

a process to ensure the CBOC Report

is accurate and complete; (3) provide

guidance or training to VISNs and 

VAMCs on how to use the CBOC

Report; and (4) require use of the 

CBOC Report as an oversight tool. VA 

concurred with all of GAO's 

recommendations and identified 

actions it is taking to implement them.
Page i GAO-18-375 VHA Community-Based Outpatient Clinics

Letter 1

Background 6

VHA-Operated CBOCs Provided Proportionally More Specialty 

Care and Had Higher Expenditures than Contracted CBOCs in 

Fiscal Years 2014 through 2016 9

VHA Has Not Fully Implemented Policy Requirements, and 

Inaccurate Information Limits Its Oversight of CBOC Quality of 

Care 15

Conclusions 21

Recommendations for Executive Action 21

Agency Comments 21

Appendix I Comments from the Department of Veterans Affairs 24

Appendix II GAO Contact and Staff Acknowledgments 27

Tables

Table 1: Site Selection for Interviews with Community-Based 

Outpatient Clinics (CBOC) 5

Table 2: Average Expenditures per Encounter by Veterans Health 

Administration (VHA)-Operated and Contracted 

Community-Based Outpatient Clinics (CBOC), Fiscal 

Years 2014 – 2016 11

Figures

Figure 1: Veterans Health Administration (VHA) Outpatient Sites 

of Care, as of September 30, 2016 7

Figure 2: Service Types Provided at Veterans Health 

Administration (VHA)-Operated and Contracted 

Community-Based Outpatient Clinics (CBOC), Fiscal 

Year 2016 10

Figure 3: Veterans Health Administration (VHA)-Operated and 

Contracted Community-Based Outpatient Clinics (CBOC) 

Average per-Encounter Expenditures by Service Type, 

Fiscal Year 2016 13

Contents
Page ii GAO-18-375 VHA Community-Based Outpatient Clinics

Abbreviations 

CBOC community-based outpatient clinic

HEDIS Healthcare Effectiveness Data and Information Set

VA Department of Veterans Affairs

VAMC VA medical center

VAST VHA site tracking 

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

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Page 1 GAO-18-375 VHA Community-Based Outpatient Clinics

441 G St. N.W.

Washington, DC 20548

April 12, 2018

Congressional Requesters

The Department of Veterans Affairs’ (VA) Veterans Health Administration 

(VHA) operates one of the largest health care delivery systems in the 

United States. In fiscal year 2016, VHA’s health care system included 168 

VA medical centers (VAMC) that offered inpatient, outpatient, and 

residential services and 733 community-based outpatient clinics 

(CBOC)—stand-alone clinics that are geographically separate from 

VAMCs and provide outpatient primary care, mental health care, and, in 

some cases, specialty care services. In fiscal year 2016, these clinics 

provided care to more than 3 million veterans at a cost of $5.3 billion, 

which represented about half of the veterans treated by VHA and nearly 

10 percent of total spending for their care. Although most CBOCs (632 of 

the 733) are owned and operated by VHA, about 14 percent (101) are 

operated by non-VHA health care organizations that contract with VHA to 

provide services.1 According to VHA, as of the end of fiscal year 2016, 29 

contractors held CBOC contracts, for which VHA spent nearly $312 

million.2 It is VHA policy that all CBOCs provide one standard of care that 

is of high quality, regardless of whether they are VHA-operated or 

contracted.

In May 2000, VHA published the last in a series of reports in response to 

a 1998 request from the Under Secretary for Health to evaluate CBOC 

performance.3 The evaluation found that VHA-operated and contracted 

CBOCs performed equally on most performance measures, but 

contracted clinics provided fewer primary care visits, had fewer patients 

 1

The Veterans’ Health Care Eligibility Reform Act of 1996 authorizes the Department of 

Veterans Affairs to obtain health care resources by entering into contracts or other 

agreements with any health care facility, entity, or individual. Pub. L. No. 104-262, § 301, 

110 Stat. 3177, 3191 (1996). Veterans Health Administration policy for acquisition of 

health care resources through contracting is documented in Department of Veterans 

Affairs, Health Care Resources Contracting – Buying, VHA Directive 1663. (Washington, 

D.C.: Aug. 10, 2006). 

2

A single contract can include multiple CBOCs and a single contractor can hold more than 

one CBOC contract. 

3

A. Hedeen et al., CBOC Performance Evaluation, Performance Report 3: Quality of Care 

Measures Based on Medical Review, a report prepared for the Department of Veterans 

Affairs, May 2000. 

Letter
Page 2 GAO-18-375 VHA Community-Based Outpatient Clinics

with mental health diagnoses, and did not have adequate cost data 

available to compare their costs to those clinics operated by VHA. Since 

that time, outpatient care use in VHA has grown substantially. In 2015, an 

external assessment of VHA reported that between 2007 and 2014, VHA 

outpatient visits increased 41 percent while inpatient bed days declined 9 

percent.4 The 2015 assessment also reported that VHA’s planning 

models predicted inpatient bed days would decline by at least another 50 

percent over the next 20 years.

We and others have cited longstanding concerns about VHA’s oversight 

of its health care system. These concerns contributed to veterans’ health 

care being placed on GAO’s High-Risk List beginning in 2015.5 You 

asked us to conduct a management review of VHA that included, among 

other issues, its use of contracts to carry out core functions.6 In this 

report, we examine the extent to which:

 4

McKinsey & Company Inc., Independent Assessment of the Health Care Delivery 

Systems and Management Processes of the Department of Veterans Affairs, Assessment 

K (Facilities), (Sept.1, 2015). The assessment was mandated by the Veterans Access, 

Choice, and Accountability Act of 2014. Pub. L. No. 113-146, § 201(a)(1), 128 Stat. 1754, 

1769-71 (2014). It included 12 specific assessment areas and, according to VA, resulted 

in 188 recommendations for reforming VHA. See Centers for Medicare & Medicaid 

Services Alliance to Modernize Healthcare Federally Funded Research and Development 

Center, Independent Assessment of the Health Care Delivery Systems and Management 

Processes of the Department of Veterans Affairs, Volume I: Integrated Report (Sept. 1, 

2015).

5

GAO maintains a high-risk list to focus attention on government agencies and programs 

that it identifies as high risk due to their greater vulnerabilities to fraud, waste, abuse, and 

mismanagement or the need for transformation to address economy, efficiency, or 

effectiveness challenges. GAO, High-Risk Series: Progress on Many High-Risk Areas, 

While Substantial Effort Needed on Others, GAO-17-317 (Washington, D.C.: Feb. 15, 

2017). 

6

We have previously issued several reports that addressed specific aspects of VHA’s 

management, including those pertaining to its policy management, human capital 

management, strategic planning, and organizational structure. See GAO, Veterans Health 

Care: Additional Actions Could Further Improve Policy Management, GAO-17-748 

(Washington, D.C.: Sept. 22, 2017); Veterans Affairs: Improved Management Processes 

Are Necessary for IT Systems That Better Support Health Care, GAO-17-384 

(Washington, D.C.: June 21, 2017); VA Health Care: Improvements Needed in Data and 

Monitoring of Clinical Productivity and Efficiency, GAO-17-480 (Washington, D.C.: May 

24, 2017); Veterans Health Administration: Management Attention Is Needed to Address 

Systemic, Long-standing Human Capital Challenges, GAO-17-30 (Washington D.C.: Dec. 

23, 2016); Veterans Health Care: Improvements Needed in Operationalizing Strategic 

Goals and Objectives, GAO-17-50 (Washington D.C.: Oct. 21, 2016); and VA Health Care: 

Processes to Evaluate, Implement, and Monitor Organizational Structure Changes 

Needed, GAO-16-803 (Washington D.C.: Sept. 27, 2016). 
Page 3 GAO-18-375 VHA Community-Based Outpatient Clinics

1. VHA-operated and contracted CBOCs vary in their provision of health 

care services; and

2. VHA oversees CBOC operations, including ensuring the same quality 

of care at both VHA-operated and contracted CBOCs.

To determine the extent to which VHA-operated and contracted CBOCs 

vary in their provision of health care services, we analyzed fiscal years 

2014 through 2016 expenditure and encounter data (the three most 

recent fiscal years of data available) for the 687 of 733 CBOCs that 

provided care as of September 30, 2016, and for which these data were 

available.7 We compared expenditures per encounter and the types of 

services provided by VHA-operated clinics to those for contracted clinics.8

We also spoke to officials from VHA’s central office about the factors that 

influence per-encounter expenditure variation across CBOCs. Given that 

our 3-year analysis period was relatively short, we did not adjust the 

values for inflation. We assessed the reliability of the encounter and 

expenditure data by checking for missing values and obvious errors and 

discussing them with VHA officials who were knowledgeable about the 

data. We analyzed the data as reported by CBOCs in VHA’s managerial 

cost accounting system and we did not independently verify the accuracy 

or completeness of the information, or the methodology used by VHA to 

 7

VHA requires all facilities to record and report data on expenditures and encounters in 

VHA’s managerial cost accounting system. VHA defines an encounter as a professional 

contact between a patient and a practitioner vested with responsibility for diagnosing, 

evaluating, and treating the patient’s condition. Encounters can occur in both the 

outpatient and inpatient settings, and can include face-to-face interactions or those 

accomplished through telecommunications technology.

Of 733 CBOCs providing care as of September 30, 2016, we analyzed encounter and 

expenditure data from 687 CBOCs—589 that were VHA-operated and 98 that were 

contracted. Data were not available for 46 CBOCs because, according to VHA officials, 

encounter and expenditure data for these CBOCs were combined with data from the 

VAMC and could not be reliably separated. Further, 24 of the 687 CBOCs included in our 

analysis did not have 3 full fiscal years of data because they were new sites that began 

operating during the time period; we included data that were available. 

8

VHA pays contracted CBOCs a capitated per-member per-month rate that combines both 

direct and indirect expenditures—that is, a rate that covers the contractors’ direct 

expenditures of providing care, as well as other indirect expenditures, such as overhead. 

These direct and indirect expenditures for contracted CBOCs cannot be separated from 

one another in VHA’s managerial cost accounting system, unlike for VHA-operated 

CBOCs. Therefore, we examined total expenditures, which include both direct and indirect 

expenditures. For the VHA-operated CBOCs, we did not evaluate the methodology used 

by VHA to allocate indirect expenditures. 
Page 4 GAO-18-375 VHA Community-Based Outpatient Clinics

calculate total costs for VHA-operated clinics.9 After taking these steps, 

we determined the data were sufficiently reliable for the purposes of this 

reporting objective.

In addition, we interviewed officials from eight selected CBOCs and from 

the four VAMCs and the four Veterans Integrated Service Networks 

(VISN) that oversee them.10 We also interviewed the four VHA contracting 

officers associated with the contracted CBOCs.11 The eight selected 

clinics are a nongeneralizable sample of four pairs of VHA-operated and 

contracted CBOCs. (See table 1.) We selected these clinics from a list of 

CBOCs that provided services as of March 10, 2017—the most recently 

available data at the time of our review—using data from the VHA site 

tracking (VAST) system, which lists all facilities and their characteristics. 

We selected the clinics for variation in geographic diversity, parent VAMC 

complexity level, clinic type (multi-specialty vs. primary care), and clinic 

size.12 We also interviewed officials from the American Legion, a veterans 

service organization, to obtain the perspective of veterans on the services 

provided at CBOCs. The information from our interviews is not 

generalizable to all CBOCs, VAMCs, VISNs, or contracting officers. We 

assessed the reliability of the VAST system data on clinic characteristics 

by reviewing relevant documentation and speaking to knowledgeable 

agency officials. We also performed data reliability checks, such as 

examining the data for missing values and obvious errors to test the 

 9

GAO has previously found that challenges exist in accurately determining the costs 

performed by federal versus contractor personnel. See GAO, Human Capital: 

Opportunities Exist to Further Improve DOD’s Methodology for Estimating the Costs of Its 

Workforces, GAO-13-792 (Washington, D.C.: Sept. 25, 2013).

10VHA organizes its system of care into regional networks called VISNs. Each VISN is 

responsible for coordination and oversight of all administrative and clinical activities within 

its specified geographic region. Specifically, the 18 VISNs oversee the day-to-day 

functions of VAMCs and CBOCs within their geographical regions. 

11Each contracted CBOC is assigned a VHA contracting officer who works with the VISN 

and the VAMC to oversee the contract. We also spoke to two of the three contractors that 

administered the contracted CBOCs in our review; the third contractor was not available to 

speak with us during the time frame of our review.

12Both multi-specialty and primary care CBOCs provide primary care and mental health 

care services. Multi-specialty CBOCs provide two or more specialty care services on-site. 

We used the total number of encounters in fiscal year 2016 as a proxy for clinic size. VHA 

assigns each VAMC to one of five complexity groups (1a, 1b, 1c, 2, or 3) using a facility 

complexity model where level 1a facilities are the most complex and level 3 facilities are 

the least complex. VHA uses multiple variables to measure facility complexity in four 

categories: patient population served, clinical services offered, education and research 

complexity, and administrative complexity. 
Page 5 GAO-18-375 VHA Community-Based Outpatient Clinics

internal consistency and reliability of the data. After taking these steps, 

we determined the data were reliable for the purposes of selecting sites 

and determining the complete list of CBOCs.

Table 1: Site Selection for Interviews with Community-Based Outpatient Clinics (CBOC) 

CBOC State Department of Veterans 

Affairs medical center (VAMC)

Veterans Integrated 

Service Network

Veterans Health 

Administration 

(VHA)-operated or 

contracted

Binghamton NY Syracuse VAMC 2 VHA-operated

Watertown NY Contracted

Anderson SC William Jennings Bryan Dorn 

VAMC

7 VHA-operated

Rock Hill SC Contracted

Gillette WY Sheridan VAMC 19 VHA-operated

Powell WY Contracted

Fergus Falls MN Fargo VAMC 23 VHA-operated

Williston ND Contracted

Source: GAO analysis of VHA data. | GAO-18-375

To evaluate the extent to which VHA oversees CBOC operations, 

including ensuring the same quality of care at both VHA-operated and 

contracted CBOCs, we reviewed VHA policies, including Directive 1229 

that establishes VHA and VISN oversight responsibilities for outpatient 

sites of care, including CBOCs.13 We also reviewed and interviewed 

officials about VHA’s CBOC Report that documents clinical quality of care 

measures for both VHA-operated and contracted clinics.14 In addition, we 

analyzed the report from the first quarter of 2017—the most recently 

available report at the time of our review—and compared CBOCs in the 

report against sites in the VAST system as of January 3, 2017. We also 

interviewed officials from VHA central office and our selected clinics 

(including the contracting officers for our selected contracted clinics), as 

well as officials from the selected clinics’ VAMCs and VISNs. We 

 13Department of Veterans Affairs, Veterans Health Administration, Planning and Operating 

Outpatient Sites of Care, VHA Directive 1229. (Washington, D.C.: July 7, 2017). 

14The CBOC Report is prepared and distributed by VHA’s Reporting, Analytics, 

Performance, Improvements and Development office within the office of the Deputy Under 

Secretary for Health for Organizational Excellence. An official from this office told us that 

they began producing the report in 2009 to compare quality of care between VHAoperated and contracted CBOCs.
Page 6 GAO-18-375 VHA Community-Based Outpatient Clinics

assessed the oversight activities performed by VHA’s central office and 

the VISNs in the context of the federal standards for internal control.15

We conducted this performance audit from February 2017 to April 2018 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Over the last decade, VHA has increasingly provided care on an 

outpatient basis, including primary care and mental health care services. 

VHA Handbook 1006.02, VHA Site Classifications and Definitions, 

defines classifications for outpatient sites of care including CBOCs.16

VHA’s Directive 1229, Planning and Operating Outpatient Sites of Care, 

outlines the process for establishing new CBOCs.17

VHA provides outpatient care through CBOCs, health care centers, and 

other outpatient services sites, which are defined in VHA’s site 

classification policy:18

• CBOCs are clinics that provide primary care and mental health care 

services, and also may provide specialty care services such as 

cardiology or neurology, in an outpatient setting. CBOCs can provide 

a wide array of services, ranging from a small, mainly telehealth clinic 

with one technician and a nurse, to a large clinic with several specialty 

 15GAO, Standards for Internal Control in the Federal Government. GAO-14-704G 

(Washington, D.C.: Sept. 10, 2014). Internal control is a process effected by an entity’s 

oversight body, management, and other personnel that provides reasonable assurance 

that the objectives of an entity will be achieved.

16Department of Veterans Affairs, Veterans Health Administration, VHA Site 

Classifications and Definitions, VHA Handbook 1006.02 (Washington, D.C.: Dec. 30, 

2013). Classifications are tracked in VAST. 

17VHA Directive 1229. 

18VHA Handbook 1006.02. 

Background

VHA’s Outpatient Sites of 

Care
Page 7 GAO-18-375 VHA Community-Based Outpatient Clinics

care services and providers.19 Each clinic is overseen by, and 

separate from, its VAMC; each VAMC in turn is overseen by one of 18 

VISNs.

• Health care centers are large multi-specialty outpatient clinics that 

provide primary care, mental health care, and on-site surgical 

services, in addition to other health care services.

• Other outpatient services sites provide nonclinical services, such as 

social services, homelessness services, and support services. They 

may also provide services that are clinical in nature through telehealth 

or other arrangements. (See fig. 1.) 

Figure 1: Veterans Health Administration (VHA) Outpatient Sites of Care, as of September 30, 2016

Note: Fiscal year 2016 was the most recent complete fiscal year of data available at the time of our 

review.

a

CBOCs are clinics that provide primary care and mental health care services, and also may provide 

specialty care services such as cardiology or neurology, in an outpatient setting.

 19Telehealth refers to clinical services provided remotely via telecommunications 

technologies. For more information on how telehealth is used in VA and other federal 

programs, see GAO, Health Care: Telehealth and Remote Patient Monitoring Use in 

Medicare and Selected Federal Programs, GAO-17-365 (Washington, D.C.: Apr. 14, 

2017). 
Page 8 GAO-18-375 VHA Community-Based Outpatient Clinics

b

Health care centers are large multi-specialty outpatient clinics that provide primary care, mental 

health care, and on-site surgical services, in addition to other health care services.

c

Other outpatient services sites provide nonclinical services, such as social services, homelessness 

services, and support services. They may also provide services that are clinical in nature through 

remote telecommunications technologies or other arrangements.

To establish a new CBOC, VHA’s policy states that the VAMC and VISN 

must ensure that one is needed by first exhausting existing VHA 

resources (such as changing clinic hours or staffing) and determining that 

VHA community care programs cannot meet the identified demand.20 The 

VAMC and VISN follow several steps to assess the need for a new clinic:

• Step 1—The VAMC and VISN identify an underserved area using 

VHA models that project changes in the veteran population and trends 

in veterans’ health care needs.

• Step 2—The VAMC develops a detailed proposal for the new clinic—

an Access Expansion Plan—that includes information such as 

whether the proposed clinic will be VHA-operated or contracted, 

projected workload, scope of the services to be provided, and cost. It 

also describes, as required by VHA policy, how the VAMC has 

exhausted existing VHA resources before proposing a new clinic.

• Step 3—The VISN reviews the expansion plan, and if approved 

forwards it to an interdisciplinary panel at VHA’s central office, which 

reviews it. A list of approved clinics is then sent to the Under 

Secretary for Health for endorsement.

• Step 4—Endorsed clinics are included in the VISN’s Strategic Capital 

Investment Planning process submission for the fiscal year.21 Final 

approval and funding for a new CBOC is dependent on Office of 

Management and Budget approval of VA’s budget submission and 

VHA’s final appropriations.

In fiscal year 2015, VHA suspended the establishment of new CBOCs 

beginning in fiscal year 2018 due to several factors, including budget 

 20VHA Directive 1229. When care is not readily accessible from VA providers, VA may 

purchase care from non-VA providers under various community care programs. Such care 

is provided under the following statutory authorities: 38 U.S.C. §§ 1703, 1725, 1728, 8111, 

and 8153. 

21The Strategic Capital Investment Planning process is VHA’s mechanism for planning 

and prioritizing capital projects. For more information on the process, see GAO, VA Real 

Property: VA Should Improve Its Efforts to Align Facilities with Veterans’ Needs, 

GAO-17-349 (Washington, D.C.: Apr. 5, 2017). 

VHA’s Process for 

Establishing New CBOCs
Page 9 GAO-18-375 VHA Community-Based Outpatient Clinics

constraints and an emphasis on the use of VHA community care 

programs. However, VISNs can submit requests for exceptions to the 

Deputy Under Secretary for Health for Operations and Management for 

review. VHA officials told us 11 exceptions had been granted as of 

February 2018.

We found that VHA-operated CBOCs provided more specialty care and 

less primary care and mental health care as a proportion of their total 

provided services than contracted CBOCs in fiscal years 2014 through 

2016. For example, in fiscal year 2016, specialty care (e.g., cardiology, 

gastroenterology, physical therapy) comprised 13 percent of services 

provided at VHA-operated clinics and 5 percent of services provided at 

contracted clinics. In contrast, VHA-operated clinics provided 

proportionally less primary care and mental health services (services 

offered at all CBOCs) in fiscal year 2016—these services comprised 66 

percent of the services provided at VHA-operated clinics, but 84 percent 

of the services provided at contracted clinics. (See fig. 2.)

VHA-Operated 

CBOCs Provided 

Proportionally More 

Specialty Care and 

Had Higher 

Expenditures than 

Contracted CBOCs in

Fiscal Years 2014 

through 2016

VHA-Operated CBOCs 

Provided Proportionally 

More Specialty Care and 

Less Primary Care and 

Mental Health Care than 

Contracted CBOCs
Page 10 GAO-18-375 VHA Community-Based Outpatient Clinics

Figure 2: Service Types Provided at Veterans Health Administration (VHA)-Operated 

and Contracted Community-Based Outpatient Clinics (CBOC), Fiscal Year 2016

Notes: As of September 30, 2016, there were 733 CBOCs—632 VHA-operated and 101 contracted. 

For these analyses, data were missing for 46 CBOCs; VHA only recorded data for these clinics at the 

Department of Veterans Affairs medical center level. Therefore, we analyzed data for 687 CBOCs—

589 VHA-operated and 98 contracted.

We measured services provided through encounters, which VHA defines as a professional contact 

between a patient and a practitioner vested with responsibility for diagnosing, evaluating, and treating 

the patient’s condition. Encounters can occur in both the outpatient and inpatient settings, and can 

include face-to-face interactions or those accomplished through telecommunications technology.

Percentages do not add to 100 due to rounding.

a

Specialty care services include cardiology, gastroenterology, and rehabilitation services (e.g., 

physical therapy).

b

Support services include radiology and laboratory services.

c

All other services include nutrition and social work services.

We found that VHA-operated CBOCs provided several specialty care 

services that were not offered in contracted CBOCs. For example, dental 

care services and gastrointestinal endoscopy were provided by multiple 

VHA-operated clinics, but were not provided by any of the contracted 

clinics in fiscal year 2016. In addition, we found that VHA-operated clinics 
Page 11 GAO-18-375 VHA Community-Based Outpatient Clinics

were generally larger and provided more complex services than 

contracted clinics. For example, multi-specialty CBOCs (clinics that 

provide two or more on-site specialty care services, and which may offer 

procedures requiring local anesthesia or sedation) were more often VHAoperated than contracted. Of the 733 CBOCs in fiscal year 2016, 210 

were classified by VHA as multi-specialty, and nearly all of these (206) 

were VHA-operated.

Officials from the four VAMCs and VISNs in our review told us decisions 

about what types of services CBOCs provide are made on a case-bycase basis according to local needs.22 For example, officials from one 

VAMC told us they decided to add physical therapy specialty care to one 

of their VHA-operated clinics based on analysis indicating that veterans’ 

need for this care in their community would increase. Also, officials said 

they wanted to alleviate the travel burden for veterans who needed the 

care, as the next closest VHA facility that offered this care was a 2.5-hour 

drive away. Officials from another VAMC told us that they approached the 

service needs at their clinics from a regional perspective, allowing for 

veteran demand for services to be met across multiple clinics in the same 

geographic area instead of relying on one clinic to meet the need. As a 

result of this approach, VAMC officials were in the process of expanding 

services at two of its clinics.

From fiscal years 2014 through 2016, we found that VHA-operated 

CBOCs had higher per-encounter expenditures than contracted 

CBOCs—a difference ranging from 3 to 5 percent per encounter. (See 

table 2.)

Table 2: Average Expenditures per Encounter by Veterans Health Administration 

(VHA)-Operated and Contracted Community-Based Outpatient Clinics (CBOC), 

Fiscal Years 2014 – 2016 

Fiscal year VHA-Operated Contracted

2014 $219 $209

2015 $225 $218

2016 $240 $229

Source: GAO analysis of VHA data. | GAO-18-375

 22VHA policy outlines the review and approval of the expansion, reduction, or elimination 

of major clinical services or programs in VHA facilities including CBOCs. See Department 

of Veterans Affairs, Veterans Health Administration, Restructuring of VHA Clinical 

Programs, VHA Directive 1043 (Washington, D.C.: Nov. 2, 2016). 

VHA-Operated CBOCs 

Had Higher Expenditures 

than Contracted CBOCs
Page 12 GAO-18-375 VHA Community-Based Outpatient Clinics

Notes: Expenditures are not adjusted for inflation.

As of September 30, 2016, there were 733 CBOCs—632 VHA-operated and 101 contracted. For 

these analyses, data were missing for 46 CBOCs; VHA only recorded data for these clinics at the 

Department of Veterans Affairs medical center level. Therefore, we analyzed data for 687 CBOCs—

589 VHA-operated and 98 contracted. Further, 24 of the 687 CBOCs included in our analysis did not 

have 3 full fiscal years of data because they were new clinics that began operating during the time 

period of our review; we included data that were available.

VHA defines an encounter as a professional contact between a patient and a practitioner vested with 

responsibility for diagnosing, evaluating, and treating the patient’s condition. Encounters can occur in 

both the outpatient and inpatient settings, and can include face-to-face interactions or those 

accomplished through telecommunications technology.

VHA pays contracted CBOCs a capitated per-member per-month rate that combines both direct and 

indirect expenditures, which cannot be separated from one another in VHA’s managerial cost 

accounting system, unlike for VHA-operated CBOCs. Therefore, we examined total expenditures, 

which include both direct and indirect expenditures. For the VHA-operated CBOCs, we did not 

evaluate the methodology used by VHA to allocate indirect expenditures.

We also found that per-encounter expenditures for almost all service 

types were higher on average for VHA-operated CBOCs than contracted 

CBOCs in fiscal year 2016; the exception was mental health care 

services, where VHA-operated clinics’ per-encounter expenditures were 2 

percent lower than for contracted clinics. The difference in per-encounter 

expenditures was greatest for specialty care services. For example, VHAoperated clinics’ per-encounter expenditures for specialty care services 

were 46 percent higher than for contracted clinics. This is in contrast to 

primary care, where VHA-operated clinics had 11 percent higher perencounter expenditures, on average, compared to contracted clinics. 

(See fig. 3.)
Page 13 GAO-18-375 VHA Community-Based Outpatient Clinics

Figure 3: Veterans Health Administration (VHA)-Operated and Contracted Community-Based Outpatient Clinics (CBOC) 

Average per-Encounter Expenditures by Service Type, Fiscal Year 2016

Notes: Expenditures are not adjusted for inflation.

As of September 30, 2016, there were 733 CBOCs—632 VHA-operated and 101 contracted. For 

these analyses, data were missing for 46 CBOCs; VHA only recorded data for these clinics at the 

Department of Veterans Affairs medical center level. Therefore, we analyzed data for 687 CBOCs—

589 VHA-operated and 98 contracted.

VHA defines an encounter as a professional contact between a patient and a practitioner vested with 

responsibility for diagnosing, evaluating, and treating the patient’s condition. Encounters can occur in 

both the outpatient and inpatient settings, and can include face-to-face interactions or those 

accomplished through telecommunications technology.

VHA pays contracted CBOCs a capitated per-member per-month rate that combines both direct and 

indirect expenditures, which cannot be separated from one another in VHA’s managerial cost 

accounting system, unlike for VHA-operated CBOCs. Therefore, we examined total expenditures, 

which include both direct and indirect expenditures. For the VHA-operated CBOCs, we did not 

evaluate the methodology used by VHA to allocate indirect expenditures.

a

Specialty care services include cardiology, gastroenterology, and rehabilitation services (e.g., 

physical therapy).

b

Support services include radiology and laboratory services.

c

All other services include nutrition and social work services.

Officials told us that several factors can influence per-encounter 

expenditures, including (1) differences in provider compensation and 

types of providers (physicians vs. physician assistants); (2) the number of 
Page 14 GAO-18-375 VHA Community-Based Outpatient Clinics

patients with complex health conditions that generally require longer visits 

and more costly services (as opposed to patients with well-managed 

conditions); and (3) geographic differences in the cost of providing care. 

One of our selected contracted CBOCs had one of the highest perencounter expenditures for fiscal year 2016 among all clinics. Officials 

from this clinic’s VAMC told us this was due to the contractor being able 

to command a very high payment rate at the time of the contract award, 

due to temporarily strong local economic conditions, as well as being the 

only contractor in the area capable of providing the required services. 

Officials said the VAMC is in the process of awarding a new contract for 

this clinic.

Although per-encounter expenditures were generally lower for contracted 

CBOCs, officials from the VISNs and VAMCs in our review told us they 

consider several factors in determining whether a new clinic will be VHAoperated or contracted. Such factors include the ability to directly monitor 

performance and implement new standards of care, as well as the ability 

to recruit and staff the clinic. For example, officials from two VAMCs in 

our review told us that VHA-operated clinics can be easier to manage 

because the VAMC has direct control of the clinic. Officials said this 

makes it easier to implement changes to VHA standards of care without 

the need to enter into contract modification negotiations. On the other 

hand, officials from three of the four VISNs and three of the four VAMCs 

in our review told us that contractors can be more flexible than VHA in 

recruiting staff (such as the ability to offer higher salaries), making a 

contracted clinic desirable for geographic areas where VHA has 

challenges recruiting or retaining providers.
Page 15 GAO-18-375 VHA Community-Based Outpatient Clinics

We found that VHA has implemented certain oversight requirements, but 

not others described in Directive 1229—its policy that outlines VHA’s 

oversight responsibilities for outpatient sites of care, including CBOCs.23

In terms of the oversight requirements that VHA implemented, we found it 

has provided reports on patient satisfaction to VISNs and VAMCs on a 

monthly basis. Specifically, VHA distributes the results of the VHA Survey 

of Healthcare Experiences, a monthly survey of veterans’ satisfaction with 

the care they received through VHA health care facilities. In addition, VHA 

implemented the requirement to make measures related to evaluating the 

progress of outpatient sites of care, such as data on wait times, workload, 

and costs, available on an internal VHA website. However, VHA has not 

implemented other oversight requirements, which is inconsistent with 

federal standards for internal control related to monitoring, which state 

that management should establish and operate monitoring activities to 

monitor the internal control system and evaluate the results.24

We found that VHA has not implemented the following requirements in 

Directive 1229:

• VHA has not developed guidelines for monitoring the quality and 

comprehensiveness of care in CBOCs. Officials from the three VHA 

offices with responsibility for collaborating to develop guidelines for 

monitoring the quality and comprehensiveness of care in CBOCs, as 

required in the policy, told us that they are not currently developing 

these guidelines and they have no plans to do so. First, officials from 

the office of the Assistant Deputy Under Secretary for Health for 

 23VHA Directive 1229. 

24GAO-14-704G. 

VHA Has Not Fully 

Implemented Policy 

Requirements, and 

Inaccurate 

Information Limits Its 

Oversight of CBOC 

Quality of Care

VHA Has Not Fully 

Implemented CBOC 

Oversight Policy 

Requirements
Page 16 GAO-18-375 VHA Community-Based Outpatient Clinics

Policy and Planning told us they had not developed these guidelines 

because they no longer believed it was their office’s responsibility, 

despite the fact that officials from the office had helped to develop the 

recently issued policy. Second, officials from the office of the Deputy 

Under Secretary for Health for Organizational Excellence told us that 

their office was not responsible for addressing the broader issue of 

monitoring clinics. Third, officials from the office of the Deputy Under 

Secretary for Health for Operations and Management told us that 

although they do not have formal guidelines in place, they believe 

their office meets the Directive 1229 requirement as part of their 

regular VISN oversight. Officials said they collect and review VISNlevel performance data, such as patient satisfaction data, which can 

be broken down to the level of the CBOC if there is a performance 

problem. However, VHA may miss clinic performance problems that 

are not identifiable in the VISN-level data. In addition, without 

developing such guidelines, VHA has not established standardized 

processes for how it monitors CBOCs, which can lead to inconsistent 

oversight. This poses the risk that veterans may be subject to different 

standards of care depending on the clinic visited.

• VISNs do not conduct continuous quality monitoring of CBOCs 

to ensure that consistent, quality care is being delivered. We 

found that three of the four VISNs in our review largely delegated 

oversight of the CBOCs to the VAMCs, rather than conducting 

continuous quality monitoring as required in the policy. Specifically, 

officials from these VISNs said that they largely focus their oversight 

on the VAMCs and do not separately review the performance of every 

CBOC unless the VAMC informs them of a quality problem at a 

particular clinic. Officials from the remaining VISN in our review said 

they do conduct CBOC-specific oversight activities. Specifically, this 

VISN had created a performance review survey tool that it sends to 

each clinic on an annual basis, and the results are reviewed by a 

workgroup made up of VISN staff. The workgroup examines trends 

across the CBOCs, including a comparison of VHA-operated and 

contracted performance. For example, one question in the tool asks 

how an individual CBOC’s performance compares with others 

overseen by the VAMC. The delegation of oversight responsibility for 

the CBOCs to the VAMCs without consistent VISN-level oversight 

creates the potential for inconsistencies in oversight, which does not 

align with VHA policy to provide one standard of care for all clinics. 

Consequently, veterans may be subject to different standards of care 

across clinics.

• The Deputy Under Secretary for Health for Operations and 

Management has not reviewed CBOC performance with VISNs as 
Page 17 GAO-18-375 VHA Community-Based Outpatient Clinics

part of the quarterly VISN performance reviews. The Deputy Under 

Secretary for Health for Operations and Management is responsible 

for conducting reviews of VISN performance with each VISN director. 

Specifically, the office of the Deputy Under Secretary for Health for 

Operations and Management is required by VHA policy to review 

CBOC-level performance data during quarterly VISN performance 

reviews. However, officials from this office and two of the VISNs we 

contacted told us they do not specifically do this unless the VISN 

identifies a performance problem. Of the remaining two VISNs, 

officials at one VISN reported only having mid-year and year-end 

meetings with VHA central office at which they did not specifically 

discuss the CBOCs, and officials from the other VISN said they did 

not have any regular quarterly performance reviews with VHA central 

office. This lack of consistent oversight poses the risk that VHA is not 

providing one, high quality standard of care to veterans across 

CBOCs.

Directive 1229 requires VHA to provide reports to the VISNs and VAMCs 

on CBOC quality of care on a quarterly and year-end basis. We found 

that the CBOC Report, which is VHA’s only report that allows for 

comparing clinical quality of care data across VHA-operated and 

contracted CBOCs, lacks accurate and complete information.25 These 

gaps limit the CBOC Report’s usefulness as a monitoring tool to 

determine whether VHA-operated and contracted CBOCs are providing 

the same standard of care. This is inconsistent with federal standards for 

internal control for information and communication, which state that 

management should use quality information to achieve the entity’s 

objectives.26

Specifically, VHA distributes the CBOC Report to VISNs and VAMCs on a 

quarterly and year-end basis, which compiles CBOC quality of care 

performance results based on the Healthcare Effectiveness Data and 

 25The CBOC Report is prepared and distributed by VHA’s Reporting, Analytics, 

Performance, Improvements and Development office within the office of the Deputy Under 

Secretary for Health for Organizational Excellence. 

26GAO-14-704G. 

VHA’s CBOC Report 

Lacks Accurate and 

Complete Information
Page 18 GAO-18-375 VHA Community-Based Outpatient Clinics

Information Set (HEDIS)—an industry standard set of quality measures.27

VISNs and VAMCs have access to other types of CBOC performance 

data, such as patient satisfaction data and wait time data, but these data 

are not used to assess clinical quality of care and they cannot be used to 

examine performance across all CBOCs or stratified by VHA-operated 

versus contracted CBOCs. In contrast, the CBOC Report allows for the 

comparison of clinical quality of care data across all CBOCs, which can 

be stratified according to whether the clinic is VHA-operated or 

contracted.

However, we found the following issues with the CBOC Report:

• Incorrect classification of CBOCs. We compared CBOCs from the 

most recent CBOC Report at the time of our review (the first quarter of 

fiscal year 2017) against sites in the VAST system as of January 3, 

2017, which is VHA’s listing of all VHA sites of care and their 

characteristics. We found that 22 percent of sites were incorrectly 

classified as CBOCs, based on the site classifications in VAST. 

Several of these sites were much more complex, such as health care 

centers and VAMCs.28 For example, a VAMC was included in the 

report as a CBOC, but this VAMC has three specialized intensive care 

units and serves as a regional referral center for intensive inpatient 

surgery, including open heart surgery. In addition, we also identified 

sites included in the report that provided less complex services than 

those that are provided in CBOCs, such as other outpatient services 

sites.

VHA officials who produce the CBOC Report told us that, prior to the 

establishment of the VAST site classifications in 2014, they used their 

judgment to classify existing sites of care as CBOCs and they have 

not updated their classifications since then.29 For sites established 

since 2014, officials told us they use the VAST site classifications, but 

may also use their judgment in certain situations. For example, if a 

 27HEDIS is a standardized dataset designed by the National Committee for Quality 

Assurance—a private, nonprofit organization—to help consumers compare the 

performance of health plans in providing selected services. VHA has adopted HEDIS 

measures to assess the quality of care provided by facilities in the VHA health care 

system. These measures include those related to behavioral health screening, diabetes, 

and heart disease.

28Health care centers and VAMCs are, in general, highly complex and provide services 

that are much more resource-intensive than the services that are provided in CBOCs. 

29VHA Handbook 1006.02.
Page 19 GAO-18-375 VHA Community-Based Outpatient Clinics

site’s classification changed in VAST from a non-CBOC to a CBOC, 

they would make a decision about whether to classify it as a CBOC in 

the report by examining various aspects of the facility, such as the 

services provided and encounters. This procedure differs from what is 

documented in the methodology section of the CBOC Report, which 

states that site classifications are based on VAST. Further, VHA 

officials said they did not have a document available that outlined how 

they make these decisions. Because the site classifications in the 

CBOC Report are based, in part, on officials’ judgment in addition to 

the classifications in VAST, the report does not present accurate 

information on CBOCs across VHA and is of limited usefulness to 

VHA as a tool to ensure that VHA-operated and contracted CBOCs 

are providing the same standard of care that is of high quality.

• Missing CBOCs. We found that 53 CBOCs (7 percent of all CBOCs) 

were missing from the CBOC Report from the first quarter of fiscal 

year 2017, rendering the data incomplete. VHA officials provided 

examples of why a CBOC might not be included in the report. For 

example, a newer CBOC might not be included because it did not 

have quality of care data available at the time the report was 

developed. However, we identified several other sites that were listed 

in the report, despite unavailable data.

• Inaccurate summary calculations. Due to the incorrect site 

classifications and missing CBOCs, the national- and VISN-level 

summary calculations of performance in the CBOC Report were also 

inaccurate. Specifically, the report includes national- and VISN-level 

averages for each HEDIS measure, which VHA officials can use as 

benchmarks for clinic performance. These averages were overinclusive—incorporating performance results from additional sites that 

were not CBOCs, and under-inclusive—omitting performance results 

from CBOCs that were missing from the report. These inaccuracies 

may lead VHA officials to draw incorrect conclusions about the quality 

of care provided in CBOCs. For example, officials from one VAMC 

told us that they use the national averages as benchmarks against 

which they compare the performance of their CBOCs. Because this 

VAMC requires CBOCs with lower-than-average HEDIS performance 

results to develop a formal action plan to improve performance, 

officials may not be identifying clinics that are in need of an action 

plan due to the inaccuracy of the averages. In addition, VHA central 

office officials who develop the CBOC Report said that the results 

from recent reports have shown that VHA-operated and contracted 

clinics in general provided the same standard of care, but this 

conclusion may not be correct as it is based on unreliable data.
Page 20 GAO-18-375 VHA Community-Based Outpatient Clinics

• No guidance or training for use of the CBOC Report. VHA central 

office officials do not provide guidance or training specific to the 

CBOC Report to assist VISNs and VAMCs in using it to oversee

CBOCs. This is inconsistent with federal standards for internal control 

related to the control environment, which state that management 

should, among other things, develop personnel to achieve the entity’s 

objectives. Such development may include training to enable 

individuals to develop competencies appropriate for key roles.30 In our 

review of the CBOC Report from the first quarter of fiscal year 2017, 

we found that in several places in the report, shorthand text and 

acronyms were used, but not defined. In addition, although there is a 

methodology section, it is not clear that the measures described in the 

report are HEDIS measures, for which VHA makes training available. 

Several VAMC and VISN officials stated that guidance or training that 

is specific to understanding the CBOC Report would be helpful. If 

VISNs and VAMCs are not trained on how to use the report, they may 

not know how to use it to oversee CBOCs and ensure they are 

providing one standard of care that is of high quality.

• No requirement for VISNs or VAMCs to use the CBOC Report. 

VHA does not require that the CBOC Report be used as a tool to 

oversee CBOCs. As a result, we found that the report was not widely 

used. Specifically, an official from the office of the Deputy Under 

Secretary for Health for Organizational Excellence—which produces 

the CBOC Report—told us that the office’s role is to compile the 

reports and distribute them, but not to monitor performance. Officials 

from the office of the Deputy Under Secretary for Health for 

Operations and Management said that VISNs and VAMCs are 

expected to use the report as part of their CBOC oversight; however, 

we found there is no requirement that they do so. We found that 

officials from three of the four VISNs and three of the four VAMCs in 

our review were not regularly using the CBOC Report. Officials from 

one of the four VAMCs and one of the four VISNs in our review were 

using it as part of CBOC oversight activities at the time of our review. 

Officials from another VISN said that they planned to start using the 

CBOC Report after we made them aware of it during our interview. If 

VISN and VAMC officials do not use the report as a part of their 

oversight, they may be missing opportunities to compare VHAoperated and contracted CBOCs and ensure they are providing one 

standard of care that is of high quality.

 30GAO-14-704G.
Page 21 GAO-18-375 VHA Community-Based Outpatient Clinics

CBOCs are an integral part of VHA’s health care delivery system, and 

VHA requires that such clinics, whether VHA-operated or contracted, 

provide the same standard of care to veterans that is of high quality. 

Although VHA has implemented certain policy requirements for CBOC 

oversight, we found several weaknesses in its oversight that make it 

difficult to determine whether it is ensuring this consistent standard of 

care across the clinics.

Specifically, VHA has not fully implemented oversight requirements that 

align with its established policies, including a requirement to establish 

guidelines for overseeing CBOC quality of care. The CBOC Report, as 

VHA’s only report comparing clinical quality of care across both VHAoperated and contracted clinics, could be an important part of those 

guidelines. However, as it currently stands, the report is inaccurate and 

incomplete and VISNs and VAMCs are not trained on or required to use 

it; thus, it is of limited use to VHA, including the VISNs and VAMCs that 

have responsibility for CBOC oversight. As a result, VHA lacks assurance 

that both VHA-operated and contracted CBOCs are providing one 

standard of care that is of high quality.

We are making the following four recommendations to the VHA 

Undersecretary for Health:

Implement oversight requirements that align with VHA’s existing policy, 

including developing guidelines for monitoring quality of care in CBOCs. 

(Recommendation 1)

Establish a process for regularly updating the CBOC Report to ensure it 

contains an accurate and complete list of CBOCs that is consistent with 

VHA’s established site classifications. (Recommendation 2)

Ensure that VISNs and VAMCs receive guidance or training on how to 

use the CBOC Report. (Recommendation 3)

Require the use of the CBOC Report as an oversight tool for ensuring 

one standard of care that is of high quality across VHA-operated and 

contracted CBOCs. (Recommendation 4)

We provided VA with a draft of this report for its review and comment. VA 

provided written comments, which are reprinted in appendix I. In its 

Conclusions

Recommendations for 

Executive Action

Agency Comments
Page 22 GAO-18-375 VHA Community-Based Outpatient Clinics

written comments, VA concurred with all four of the report’s 

recommendations, and identified actions it is taking to implement them. 

We are sending copies of this report to the appropriate congressional 

committees, the Acting Secretary of Veterans Affairs, the Under Secretary 

for Health, and other interested parties. In addition, the report is available 

at no charge on the GAO Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or at draperd@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix II.

Debra A. Draper

Director, Health Care
Page 23 GAO-18-375 VHA Community-Based Outpatient Clinics

List of Requesters

The Honorable Johnny Isakson

Chairman

The Honorable Jon Tester

Ranking Member

Committee on Veterans’ Affairs

United States Senate

The Honorable Phil Roe

Chairman

The Honorable Tim Walz

Ranking Member

Committee on Veterans’ Affairs

House of Representatives

The Honorable Derek Kilmer

House of Representatives

The Honorable Mark Takano

House of Representatives
Appendix I: Comments from the Department of 

Veterans Affairs

Page 24 GAO-18-375 VHA Community-Based Outpatient Clinics

Appendix I: Comments from the Department 

of Veterans Affairs
Appendix I: Comments from the Department of 

Veterans Affairs

Page 25 GAO-18-375 VHA Community-Based Outpatient Clinics
Appendix I: Comments from the Department of 

Veterans Affairs

Page 26 GAO-18-375 VHA Community-Based Outpatient Clinics
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 27 GAO-18-375 VHA Community-Based Outpatient Clinics

Debra A. Draper, (202) 512-7114 or draperd@gao.gov.

In addition to the contact named above, Janina Austin, Assistant Director; 

Malissa G. Winograd, Analyst-in-Charge; Jennie F. Apter; Zhi Boon; Keith 

Haddock; and Sarah-Lynn McGrath made key contributions to this report. 

Also contributing were Jacquelyn Hamilton and Vikki Porter.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(101664)
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