VA Health Care: Reporting of Spending and Workload for Mental Health Services Could Be Improved
Published: 2010-05-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Veterans Affairs (VA) provides, or pays for, a range of mental health services for veterans. To effectively manage resources and ensure access to eligible veterans, VA needs complete spending and workload information for mental health services. This information is also important for congressional oversight GAO was asked to examine VA's mental health spending and workload. In this report, GAO examined for fiscal year 2009 (1) VA's spending for mental health services and (2) VA's workload for mental health services. GAO examined VA's reporting of mental health spending and workload data for fiscal year 2009 in its fiscal year 2011 congressional budget justification and whether VA reported these data in any other publicly available report. GAO analyzed additional mental health spending and workload data and interviewed VA officials.
section_title: What GAO Found
paragraphs: VA reported in its fiscal year 2011 congressional budget justification spending about $4.4 billion on mental health services in fiscal year 2009 in VA settings primarily used for providing mental health services. However, VA had additional spending in fiscal year 2009 for mental health services that VA did not report as mental health spending in its budget justification or in any other publicly available report. Specifically, VA did not report as mental health spending the amounts it spent for those mental health services that it (1) paid non-VA providers to provide in community settings and (2) provided in VA settings not primarily used for providing mental health services, such as nursing homes. VA also did not report as mental health spending the amount it spent for counseling services to address mental health issues provided by VA Vet Centers. Although VA did not report this spending information, VA does determine its spending for mental health services provided by non-VA providers and for outpatient mental health services provided in VA settings not primarily used for providing mental health services. According to VA officials, VA spent an additional $269 million for these services in fiscal year 2009. VA does not have complete spending information for inpatient hospital mental health services provided by mental health providers in VA settings not primarily used to provide mental health services nor does it have spending information for counseling services to address mental health issues provided by Vet Centers. In fiscal year 2009, VA provided mental health services to about 1.22 million unique patients in VA settings primarily used for providing mental health services. However, VA did not report this information in its fiscal year 2011 congressional budget justification or in any other publicly available report. VA officials said that the number of unique patients is not available until after VA's budget justification is published. Additionally, VA did not report other workload information that it has on (1) the number of encounters for outpatient services and the average daily census for each of its inpatient hospital, residential, and domiciliary services provided in VA settings primarily used for providing mental health services and (2) the workload for mental health services provided in other settings--community settings for which VA paid non-VA providers to provide mental health services and VA settings not primarily used for providing mental health services. VA also did not report the workload for counseling services to address mental health issues provided by Vet Centers, but VA is able to estimate its workload for these services. VA's reporting of mental health spending and workload does not give Congress a complete overview of VA's mental health services and limits information available for congressional oversight of VA's mental health services. Reporting additional mental health spending and workload information could enhance information available for congressional oversight.

section_title: Letter
paragraphs: The Department of Veterans Affairs (VA) operates one of the largest health  care delivery systems in the nation. VA provides, or pays for, a range of  mental health services throughout its 21 health care networks for  veterans with conditions such as depression, post-traumatic stress  disorder (PTSD), and substance use disorders. With the ongoing milita operations in Afghanistan and Iraq—Operation Enduring Freedom and  Operation Iraqi Freedom, respectively—VA has experienced an increased  demand for its mental health services. This growing demand highlights  the importance of VA’s goal to ensure that all eligible veterans, wherever  they obtain care in VA, have access to needed mental health services. To  effectively manage its resources and achieve its goal, VA needs com plete  and accurate information on the amount it spends each fiscal year to  provide mental health services and on its mental health workload, which is the amount of mental health care  VA provides.
Complete and accurate information on VA’s mental health spending and  workload is also important for congressional oversight of VA’s mental  health services. Each year, VA develops annual spending and workload  estimates for all of its medical services, including mental health care, and  provides these estimates and supporting information in the budget  justification that VA submits to the subcommittees with jurisdiction over  its appropriations as part of the annual appropriations process. This  information is used to conduct congressional oversight functions, for  example determining the adequacy of VA funding and assessing VA’s  current efforts to address the mental health care of veterans. Complete  and accurate mental health spending and workload information can help  Congress effectively oversee VA’s mental health services and identify VA’s  intended use of resources and workload.
You expressed interest in obtaining information on VA’s spending and  workload for mental health services. In this report, we examined, for fiscal  year 2009, (1) VA’s spending for mental health services and (2) VA’s  workload for mental health services. As part of this work, we also  examined VA’s reporting of its fiscal year 2009 mental health spending and  workload in VA’s fiscal year 2011 congressional budget justification and  whether VA reported this information in any other publicly available  report.
To perform our work, we obtained fiscal year 2009 data on VA’s spending  and workload for mental health services. Fiscal year 2009 data were the  most recently available spending and workload data at the time of our  review. We used the data to examine VA’s national spending and workload  for mental health services as well as VA’s spending and workload for each  of its 21 health care networks. We also interviewed VA officials from the  Veterans Health Administration’s Office of Finance, Office of Mental  Health Services, Mental Health Enhancement Initiative for Primary Care,  and Mental Health Workload and Data Analysis Workgroup. We also  obtained fiscal year 2009 data and interviewed officials from Veterans  Health Administration’s Readjustment Counseling Service to examine  workload for counseling services to address mental health issues that are  provided by Vet Centers—a nationwide system of community-based  centers that VA established separately from its medical centers to provide  readjustment counseling services to combat veterans. Fiscal year 2009  spending data were not available for Vet Centers’ counseling services to  address mental health issues. Additionally, we reviewed VA documents  and interviewed VA officials to determine VA’s reporting of spending and  workload information for the services discussed in this report in its fiscal  year 2011 congressional budget justification or whether VA reported this  information in any other publicly available report.
For our analysis of VA mental health spending, we used obligations—VA’s  cost of providing or paying for mental health services for eligible veterans,  including costs of administering mental health services, and national  overhead, which includes the operating costs for VA headquarters,  networks, and national programs. It does not include VA’s costs of  providing medications for the treatment of mental health conditions. For  our analysis of VA mental health workload, we used the following four  workload measures: (1) unique patients—unduplicated count of patients  receiving a particular type of service, (2) encounters—professional  contacts between patients and providers for outpatient services,   (3) visits—one or more professional contacts between a patient and  provider during a single day, and (4) average daily census—the average  number of patients receiving inpatient services on any given day during  the course of the year. We chose these measures because VA officials told  us that they are key measures that are relevant for measuring mental  health workload. We assessed the reliability of the information we  obtained about VA’s mental health spending and workload in several ways,  including interviewing agency officials knowledgeable about VA’s mental  health services and about VA’s mental health spending and workload data  and the processes used to calculate them. We determined that the data we  used were sufficiently reliable for the purposes of this report.
We conducted this performance audit from April 2009 through May 2010 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives. See appendix I for a complete description of  our scope and methodology.
subsections: section_title: Background
paragraphs: VA provides mental health services in each of its medical centers, which  are located throughout VA’s 21 health care networks, in settings primarily  used for providing mental health services. In these settings, which include  mental health clinics, VA provides outpatient, residential, domiciliary, and  inpatient hospital mental health services. (See table 1 for a description of  VA’s mental health services.) The mental health services provided in these  settings focus on rehabilitation- and recovery-oriented services to help  patients with severe and persistent mental illnesses, including substance  use disorders.
VA also provides mental health services in VA settings that are not  primarily used to provide mental health services, such as nursing homes  (also referred to by VA as community living centers) and spinal cord injury  clinics. Additionally, in some situations, VA pays for mental health services  provided by non-VA providers in community settings. When there are no  VA facilities near the veteran’s home or VA facilities are unable to provide  certain mental health services on site, VA is authorized to enter into  agreements with non-VA providers to provide these services. Specifically,  VA facilities can make outpatient mental health services available from  non-VA providers in the community who will accept VA payment— referred to as fee-basis care. In addition, VA facilities can contract with  non-VA hospitals in the local community for inpatient hospital services— referred to as contract care.
VA also provides counseling services that focus on mental health issues  through VA Vet Centers. The counseling services to address mental health  issues provided by Vet Centers differ from the mental health services  provided by VA medical centers in that they focus on counseling to assist  combat veterans in readjusting from wartime military service to civilian  life. For example, the Vet Centers do not diagnose veterans’ mental health  conditions. These counseling services provided by Vet Centers focus on a  range of issues, including PTSD, drug and alcohol abuse, sexual trauma,  and family issues. Veterans needing more acute care—for example,  veterans with mental health co-morbidities such as severe PTSD and  depression or those who pose a risk of harm to themselves or others—are  often referred to VA medical centers for further evaluation and treatment.  The number of Vet Centers has increased from 232 in fiscal year 2008 to  271 in fiscal year 2009. VA plans to increase the number of Vet Centers  from 271 to 300 by the end of fiscal year 2011.
section_title: VA Reported Spending about $4.4 Billion for Mental Health Services in Fiscal Year 2009, but This Amount Did Not Include All Mental Health Services
paragraphs: VA reported in its fiscal year 2011 congressional budget justification  spending about $4.4 billion in fiscal year 2009 on mental health services in  VA settings primarily used for providing mental health services. However,  VA had additional spending in fiscal year 2009—for mental health services  provided in other settings—that VA did not report as mental health  spending in its congressional budget justification or in any other publicly  available report.
subsections: section_title: VA Reported Spending about $4.4 Billion in Fiscal Year 2009 for Mental Health Services in VA Settings Primarily Used for Providing Mental Health Services
paragraphs: In its fiscal year 2011 congressional budget justification, VA reported  spending about $4.4 billion in fiscal year 2009 for mental health services  provided in VA settings primarily used for mental health services.  Outpatient services accounted for about 55 percent of this spending— about $2.4 billion—in fiscal year 2009. (See fig. 1.) VA reported spending  the remaining $2 billion on inpatient hospital services—which provide  intensive treatment for patients admitted to hospitals for mental health  conditions—and on residential and domiciliary services, which provide  rehabilitation, treatment, and a range of other services in a structured  living arrangement at a VA facility.
In fiscal year 2009, VA’s spending on mental health services provided in VA  settings used primarily for mental health services varied across VA’s 21  networks, ranging from about $123 million in Network 19 (Denver) to  about $297 million in Network 16 (Jackson). (See fig. 2.) Across VA’s  networks, outpatient services accounted for the largest percentage of each  network’s mental health spending in fiscal year 2009, followed by inpatient  hospital services, though specific spending amounts varied by each  network. According to VA officials, this variation may be caused, in part,  by the number of inpatient mental health beds within a network. Networks  with more beds would likely have higher utilization of inpatient hospital  mental health services, resulting in higher spending for mental health  services. VA officials told us that they do not have data to identify all the  factors that account for the variations in spending for mental health  services across networks.
section_title: VA Spent Additional Amounts for Mental Health Services in Fiscal Year 2009 but Did Not Report These as Mental Health Spending
paragraphs: In addition to the $4.4 billion VA reported spending in fiscal year 2009 for  mental health services provided in VA settings primarily used for mental  health, VA spent additional amounts for mental health services.  Specifically, VA (1) paid non-VA providers to provide mental health  services in community settings; (2) provided mental health services  through VA mental health providers in VA settings not primarily used for  providing mental health services, such as nursing homes and spinal cord  injury clinics; and (3) provided counseling services to address mental  health issues through Vet Centers. However, VA did not report this  spending as mental health spending in its fiscal year 2011 congressional  budget justification or in any other publicly available report.
VA determines how much it spends for some of these mental health  services. According to VA officials, VA spent about $269.4 million in fiscal  year 2009 for the following mental health services:    VA spent about $137.4 million for non-VA providers—such as community- based hospitals and mental health professionals—to provide mental health  services to patients.
VA spent about $132 million on outpatient mental health services provided  by mental health providers in VA settings not primarily used for providing  mental health services.
Although VA determines how much it spends for some of its mental health  services, it did not report fiscal year 2009 spending for these mental health  services as mental health spending in its fiscal year 2011 congressional  budget justification or in any other publicly available report. Instead,  according to VA officials, VA includes this spending as part of broader  categories of spending when reporting information in congressional  budget justifications. For example, VA’s reporting of outpatient care in its  congressional budget justification includes part of VA’s spending for  outpatient mental health services provided by non-VA providers in  community settings. VA officials told us VA does not report its spending  for mental health services provided by non-VA providers in community  settings in its congressional budget justifications because determining this  spending requires data that are not available at the time the congressional  budget justification is published.
In contrast to the mental health services for which VA determines how  much it spends, there are other mental health services for which VA does  not have spending information for fiscal year 2009. According to VA  officials, VA does not have complete spending information for inpatient  hospital mental health services provided by mental health providers in VA  settings not primarily used to provide mental health services. Additionally,  VA does not have spending information for counseling services to address  mental health issues provided by Vet Centers.
VA officials told us that VA does not determine how much it spends for  these services for several reasons. For inpatient hospital mental health  services, VA officials told us that it does not have cost information for  about 25 percent of the services. According to VA officials, determining  the costs for inpatient hospital mental health services is a new process and  VA is currently determining these costs. For counseling services to  address mental health issues provided by Vet Centers, VA officials told us  that separating spending for these services from total Vet Center spending  is difficult because most veterans receive multiple services—counseling  and social support services, such as employment and legal support—from  Vet Centers.
section_title: VA Provided Mental Health Services to More Than 1 Million Unique Patients in Fiscal Year 2009, but VA Did Not Report Workload for All of Its Mental Health Services
paragraphs: In fiscal year 2009, VA provided mental health services to about   1.22 million unique patients in VA settings primarily used for providing  mental health services. VA also provided mental health services through  VA mental health providers in other VA settings, such as community  settings for which VA paid non-VA providers to provide mental health  services. However, VA did not report workload for all of its mental health  services in its fiscal year 2011 congressional budget justification or in any  other publicly available report.
subsections: section_title: VA Provided Mental Health Services to about 1.22 Million Unique Patients in Fiscal Year 2009 in VA Settings Primarily Used for Providing Mental Health Services
paragraphs: VA provided mental health services to about 1.22 million unique patients in  fiscal year 2009 in VA settings primarily used for mental health services.  (See table 2.) Almost all of these patients received outpatient services. VA  officials said that this is primarily because patients receiving mental health  services generally only need outpatient services and do not need the more  intensive inpatient hospital and residential services. Inpatient hospital,  residential, and domiciliary mental health services accounted for  significantly smaller proportions of the total number of unique patients  receiving mental health services in fiscal year 2009.
In each of VA’s 21 networks, outpatient mental health services accounted  for the largest percentage—more than 98 percent—of each network’s total  number of unique patients receiving mental health services in fiscal year  2009. At the same time, the number of unique patients receiving outpatient  services varied widely across the networks, from about 31,000 in   Network 2 (Albany) to about 110,000 in Network 8 (Bay Pines). (See   table 3.) There was also wide variation across the networks in fiscal year  2009 in the number of outpatient encounters. In addition, VA’s networks  varied considerably in the number of unique patients receiving inpatient  hospital services, with Networks 2 (Albany) and 8 (Bay Pines) being  among the lowest and highest, respectively. (See table 4.) According to VA  officials, network variations in the number of unique patients receiving  mental health services may be due to enrollee population as well as other  factors. For example, in fiscal year 2009, Network 2 (Albany) had the  second lowest enrollee population, while Network 8 (Bay Pines) had the  highest enrollee population among all networks. VA officials told us that  they do not have data to identify all the factors that account for variations  in workload for mental health services across the networks.
VA’s 21 networks also varied widely in terms of the number of unique  patients receiving residential and domiciliary mental health services in  fiscal year 2009. For example, the number of unique patients receiving  residential mental health services ranged from 0 in Network 22 (Long  Beach) to about 1,400 in Network 12 (Chicago). (See table 5.) Network and  other VA officials told us that these variations are in part due to the  number of operating beds in each network. For example, VA officials told  us that Network 22 (Long Beach) does not have any residential beds and  that the network provides all of its residential services through agreements  with non-VA providers and through its domiciliary services.
section_title: VA Did Not Report Workload for All Mental Health Services Provided in Fiscal Year 2009
paragraphs: VA did not report workload information for all of the mental health  services it provided in fiscal year 2009 in its fiscal year 2011 congressional  budget justification or in any other publicly available report. Specifically,  VA did not report the total number of unique patients—1.22 million— receiving mental health services in fiscal year 2009 in the VA settings  primarily used for providing mental health services. VA also did not report  the number of unique patients receiving each type of service—inpatient  hospital, residential, domiciliary, or outpatient—in these settings.  Additionally, VA did not report the number of encounters for outpatient  services in fiscal year 2009 in these settings. Instead, VA reported in its  fiscal year 2011 congressional budget justification the total number of  patients treated—the number of patients discharged during the year plus  the number of patients remaining at the end of the year—for its inpatient  hospital, residential, and domiciliary mental health services. VA officials  told us that this measure—patients treated—would count a person with  multiple admissions or discharges during the fiscal year multiple times. VA  reports the total number of patients treated in its congressional budget  justifications because this information is available at the time VA’s budget  justification is published. The number of unique patients is not available  until after VA’s budget justification is published.
While VA reported the combined average daily census for inpatient  hospital, residential, and domiciliary mental health services, it did not  report the average daily census for each of these services. Further, VA  did not report the average daily census for these services with the  spending for these services in its budget justification, which VA does for  some of its services. For example, for long-term care services, VA reporte average daily census and spending in the same table and reported averag daily census for both institutional and noninstitutional care in its fiscal   VA officials said that VA  year 2011 congressional budget justification. reported the combined average daily census for mental health services in  its fiscal year 2011 congressional budget justification to be consistent  its reporting of this information in previous budget justifications.
Although VA did not report the number of encounters for outpatient  mental health services provided in VA settings primarily used for providing  mental health services, VA determines its workload for these mental  health services using this measure. VA officials told us that this workload  measure is a key measure that is relevant for measuring the workload for  mental health services.
In addition, VA did not report workload for the mental health services that  it provided in other settings—community settings for which VA paid non- VA providers to provide mental health services and VA settings not  primarily used for providing mental health services, such as nursing  homes, in which VA mental health providers provided services. VA also did  not report workload for counseling services to address mental health  issues provided by Vet Centers. According to VA’s Mental Health Workload  and Data Analysis Workgroup, any comprehensive review of mental  health in VA should include the services delivered in these settings.  According to the workgroup, VA’s ability to document the breadth and  extent of its mental health services is key for ensuring that the resources  for these services are used in the most productive and effective manner  possible.
Although VA did not report its total workload for mental health services  provided in other settings in fiscal year 2009, VA determines its workload  for some of these mental health services and was able to provide us with  workload information for these services. According to VA officials, for  fiscal year 2009:    VA paid non-VA providers to deliver inpatient hospital mental health  services in community settings to about 10,400 unique patients and  outpatient mental health services to about 11,600 unique patients. The  average daily census for the inpatient hospital services was about 250. The  outpatient services accounted for about 130,000 encounters.
VA provided mental health services in VA settings not primarily used for  providing mental health services that accounted for about 485,000  encounters with mental health providers.
According to VA’s mental health workload workgroup, the workload for  mental health services provided in community settings by non-VA  providers and in VA settings not primarily used for providing mental health  services should be reported. The workgroup stated that the workload  should not be reported with the workload for mental health services  provided in settings that primarily provide mental health, but they should  exist as a separate segment of any report. VA officials told us that while  this workload information is not discretely identified as mental health in  VA’s congressional budget justification, it is included as part of VA’s  reporting of its workload for other services. VA officials said that VA has  consistently focused its reporting of mental health services on those  services provided in established mental health clinics.
In contrast with the mental health services for which VA determines its  workload, VA does not determine its workload for the counseling services  to address mental health issues provided by Vet Centers. Similar to Vet  Centers’ spending for these counseling services, according to VA officials,  VA does not determine Vet Centers’ workload for counseling services to  address mental health issues separately from Vet Centers’ total workload  because of the difficulty associated in separating these counseling services  from other services that veterans receive through Vet Centers.  Nevertheless, VA officials estimated for us that Vet Centers provided  counseling services to address mental health issues to about 70,000  veterans in fiscal year 2009, and these veterans accounted for about  989,000 visits for counseling services to address issues such as PTSD, drug  and alcohol abuse, and family issues. According to VA’s mental health  workload workgroup, Vet Centers’ workload for these services should be  reported within the context of the mental health services they provide.
section_title: Conclusions
paragraphs: VA uses its annual congressional budget justifications to provide its  appropriations subcommittees and others with information on the  department’s spending and workload for the medical services—such as  mental health services—provided to eligible veterans in connection with  appropriation requests. However, the information VA reported in its fiscal  year 2011 congressional budget justification on its mental health services  does not reflect VA’s total mental health spending and workload. In  particular, VA did not report key workload information for mental health  services provided in VA settings primarily used for providing mental health  services. Specifically, VA did not report the number of encounters for  outpatient services or the average daily census for each of its inpatient  hospital, residential, and domiciliary services. Additionally, VA did not  report the spending and workload for mental health services provided in  other settings that are key to VA’s efforts to meet the mental health needs  of veterans: VA settings not primarily used for providing mental health  services and community settings where VA pays non-VA providers to  provide mental health services. Although VA determines the amount it  spends for some of these services, it did not report this information as  mental health information in its fiscal year 2011 congressional budget  justification or in any other publicly available report. Furthermore, VA  does not determine and did not report spending and workload for the  counseling services to address mental health issues provided by Vet  Centers in its congressional budget justification or in any other publicly  available report.
VA’s reporting of mental health spending and workload does not give  Congress a complete overview of VA’s mental health services and limits  information available for congressional oversight. Reporting additional  mental health spending and workload information could enhance  information available for congressional oversight.
section_title: Recommendations for Executive Action
paragraphs: To enhance information available for congressional oversight and use by  stakeholders on VA’s spending and workload for mental health services,  we recommend that the Secretary of Veterans Affairs take the following  four actions:  include workload information, including number of encounters and  average daily census, by type of service, for mental health services  provided in VA settings primarily used for providing mental health services  with its presentation of mental health spending in its annual congressional  budget justification; include spending and workload information, including number of  encounters and average daily census, for mental health services that VA  pays non-VA providers to deliver in community settings in its annual  congressional budget justification, or in a separate, annual, publicly  available report soon after the information becomes available; include spending and workload information, including number of  encounters and average daily census, for mental health services provided  in VA settings not primarily used for providing mental health services in its  annual congressional budget justification, or in a separate, annual, publicly  available report soon after the information becomes available; and include workload information, including number of visits, for counseling  services to address mental health issues provided by Vet Centers in its  annual congressional budget justification, or in a separate, annual, publicly  available report soon after the information becomes available.
We also recommend that the Secretary of Veterans Affairs direct the  Under Secretary for Health to identify ways of incorporating spending  information for Vet Center counseling services that address mental health  issues in VA’s annual congressional budget justification or in a separate,  annual, publicly available report soon after the information becomes  available.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to VA for comment. In its written  comments, reproduced in appendix II, VA concurred with three of our  recommendations but did not concur with our recommendations related  to Vet Center counseling services to address mental health issues.  Specifically, VA concurred with our first recommendation to include  workload information for mental health services provided in VA settings  primarily used for providing mental health services with its presentation of  mental health spending in its annual congressional budget justification. VA  noted that it plans to provide this information in its fiscal year 2012  congressional budget justification. VA also concurred with our second and  third recommendations to include spending and workload information for  mental health services that (a) VA pays non-VA providers to deliver in  community settings and (b) VA provides in settings not primarily used for  providing mental health services in its annual congressional budget  justification, or in a separate, annual, publicly available report soon after  the information becomes available. VA noted that it would provide the  spending and workload information publicly in a separate, annual, report  by April 2011.
VA did not concur with our recommendations related to Vet Centers’  reporting of spending and workload information for counseling services to  address mental health issues. VA noted that Vet Centers provide a unique  type of readjustment counseling that differs from the mental health  services provided at VA medical centers, and that it is important not to  report these activities as if they were traditional mental health activities.  VA said that reporting Vet Center activities this way will detract from the  structure that brings in many combat veterans and military sexual trauma  clients and underreports the full scope of Vet Center activities. VA also  said that because Vet Center workload and spending are intricately  interwoven and directly aligned to the Vet Center, VA is unable to report  one or the other independently within the traditional mental health  services. We agree that Vet Centers provide a unique type of counseling  that differs from the mental health services provided at VA medical  centers, and have described differences between the two in this report. We  have pointed out, for example, that Vet Centers do not diagnose mental  health conditions, but instead provide counseling services to address  mental health issues—such as PTSD and drug and alcohol abuse—as one  of the services they provide.
We believe that our recommendations related to Vet Centers could be  implemented while addressing VA’s concerns. In this report, we are  recommending that VA report Vet Center workload for counseling services  to address mental health issues and identify ways of incorporating  spending information for these services; not that Vet Center activities be  reported as traditional mental health services. We believe that VA could  report this information in a way that is consistent with the unique services  Vet Centers provide and does not limit VA’s reporting of Vet Centers’  activities. Moreover, we believe that VA can provide workload data for Vet  Center counseling services to address mental health issues separately  from Vet Centers’ total workload. VA provided estimates included in this  report for Vet Center workload, measured by visits, for counseling services  to address mental health issues. Therefore, we believe that such  information could be reported. Finally, we believe that reporting  information on Vet Center spending and workload could enhance  information available for congressional oversight and that this reporting  could be done in a manner that maintains the distinction between services  provided by Vet Centers and VA medical centers.
We are sending copies of this report to the Secretary of Veterans Affairs. 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 williamsonr@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To examine the Department of Veterans Affairs’ (VA) spending and  workload for mental health services, we examined, for fiscal year 2009,   (1) VA’s spending for mental health services and (2) VA’s workload for  mental health services. As part of this work, we examined VA’s reporting  of its fiscal year 2009 spending and workload information in VA’s fiscal  year 2011 congressional budget justification and whether VA reported this  information in any other publicly available report. To examine VA’s  spending and workload for mental health services that VA provided in VA  medical centers and that VA paid non-VA providers to provide in  community settings, we analyzed national- and network-level data for  fiscal year 2009 obtained from the Veterans Health Administration Office  of Finance. To examine VA’s workload for counseling services to address  mental health issues that are provided by VA Vet Centers, we analyzed  data obtained for fiscal year 2009 from the Veterans Health  Administration’s Readjustment Counseling Service. Fiscal year 2009  spending data were not available for Vet Centers’ counseling services to  address mental health issues. Fiscal year 2009 data were the most recently  available spending and workload data at the time of our review. To help us  understand how VA approaches mental health spending and workload, we  also reviewed VA’s fiscal year 2008 spending and workload data, but we  did not include these data in the report.
For our analysis of VA mental health spending, we used obligations—VA’s  cost of providing or paying for mental health services, including costs of  administering mental health services, and national overhead, which  includes the operating costs for VA headquarters, networks, and national  programs. We used obligations because VA reports obligations for mental  health services in its annual congressional budget submissions and VA  officials told us they routinely determine VA’s spending for mental health  services using obligations data. Our analysis of VA mental health spending  does not include VA’s costs of providing medications for the treatment of  mental health conditions. For our analysis of VA’s mental health workload  in its medical centers, in community settings where VA pays non-VA  providers to provide mental health services, and in Vet Centers, we used  the following four workload measures: (1) unique patients—unduplicated  count of patients receiving a particular type of service, (2) encounters— professional contacts between patients and providers for outpatient  services, (3) visits—one or more professional contacts between a patient  and a provider on a single day, and (4) average daily census—the average  number of patients receiving inpatient hospital, residential, or domiciliary  services on any given day during the course of the year. We chose these  measures because VA officials told us that they are key measures that are  relevant for measuring mental health workload.
To examine variation in spending and workload we identified across VA’s  networks, we conducted phone interviews with officials from a  judgmental sample of four VA networks—Network 3 (Bronx), Network 8  (Bay Pines), Network 17 (Dallas), and Network 22 (Long Beach). We  selected these networks based on variation in geographic location, mental  health spending and workload, and the number of veterans enrolled in the  network. We also visited VA’s Perry Point, Maryland, medical center to  better understand how VA provides and pays for mental health services.  We selected this medical center based on the range of mental health  services it provides and the medical center’s proximity to Washington,  D.C.
We also interviewed officials from VA’s Veterans Health Administration  Office of Finance, Readjustment Counseling Service, Office of Mental  Health Services, Mental Health Enhancement Initiative for Primary Care,  and Mental Health Workload and Data Analysis Workgroup. We  interviewed these officials to obtain information on VA’s efforts to  determine and report complete and accurate information on its spending  and workload for mental health services. We also examined VA’s reporting  of mental health spending and workload in its congressional budget  justifications for fiscal years 2006 through 2011 and whether VA reported  this information in any other publicly available report.
We assessed the reliability of the national- and network-level data on VA’s  spending and workload for mental health services in several ways. First,  we checked for internal consistency of VA documents detailing VA’s  spending and workload for mental health services for fiscal year 2009.  Second, we compared the fiscal year 2009 spending and workload data we  obtained from VA with the fiscal year 2009 mental health data VA reported  in its fiscal year 2011 congressional budget justification. We also compared  fiscal year 2009 spending and workload data with VA’s fiscal year 2008  spending and workload data. Third, we interviewed agency officials  knowledgeable about VA’s mental health services and about VA’s mental  health spending and workload data and the processes used to calculate  them. We determined that the data we used in our analyses were  sufficiently reliable for the purposes of this report.
We conducted this performance audit from April 2009 through May 2010 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, James Musselwhite, Assistant  Director; Janina Austin; Romuladus Azuine; Krister Friday; and Sarah  Harvey made key contributions to this report.