VA Health Care: VA Lacks Accurate Information about Outpatient Medical Appointment Wait Times, Including Specialty Care Consults
Published: 2014-05-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Access to timely medical appointments is critical to ensuring that veterans obtain needed medical care. Over the past few years, there have been numerous reports of VAMCs failing to provide timely care to patients, including specialty care, and in some cases, these delays have resulted in harm to patients.
In December 2012, GAO reported that improvements were needed in the reliability of VHA's reported medical appointment wait times, as well as oversight of the appointment scheduling process. Also in 2012, VHA found that systemwide consult data could not be adequately used to determine the extent to which veterans experienced delays in receiving outpatient specialty care. In May 2013, VHA launched the Consult Management Business Rules Initiative with the aim of standardizing aspects of the consults process.
This statement highlights (1) preliminary observations GAO made in an April 9, 2014, testimony statement regarding VHA's management of outpatient specialty care consults, and (2) concerns GAO raised in its December 2012 report regarding VHA's outpatient medical appointment scheduling, and progress made implementing GAO's recommendations. To conduct this work, GAO reviewed documents and interviewed officials from VHA's central office. Additionally, GAO interviewed officials from five VAMCs for the consults work and four VAMCs for the scheduling work that varied based on size, complexity, and location.
section_title: What GAO Found
paragraphs: As GAO previously reported in its testimony on April 9, 2014, its preliminary work examining the Department of Veterans Affairs' (VA), Veterans Health Administration's (VHA) management of outpatient specialty care consults identified examples of delays in veterans receiving outpatient specialty care, as well as limitations in the implementation of new consult business rules designed to standardize aspects of the clinical consult process. For example, for 4 of the 10 physical therapy consults GAO reviewed for one VA medical center (VAMC), between 108 and 152 days elapsed with no apparent actions taken to schedule an appointment for the veteran. For 1 of these consults, several months passed before the veteran was referred for care to a non-VA health care facility. VAMC officials cited increased demand for services, and patient no-shows and cancelled appointments among the factors that lead to delays and hinder their ability to meet VHA's guideline of completing consults within 90 days of being requested. GAO's preliminary work also identified variation in how the five VAMCs reviewed have implemented key aspects of VHA's business rules, such as strategies for managing future care consults—requests for specialty care appointments that are not clinically needed for more than 90 days. Such variation may limit the usefulness of VHA's data in monitoring and overseeing consults systemwide. Furthermore, oversight of the implementation of the business rules has been limited and has not included independent verification of VAMC actions. Because of the preliminary nature of this work, GAO is not making recommendations on VHA's consult process at this time.
In its December 2012 report, GAO found that VHA's outpatient medical appointment wait times were unreliable. The reliability of reported wait time performance measures was dependent in part on the consistency with which schedulers recorded desired date—defined as the date on which the patient or health care provider wants the patient to be seen—in the scheduling system. However, VHA's scheduling policy and training documents were unclear and did not ensure consistent use of the desired date. GAO also found that inconsistent implementation of VHA's scheduling policy may have resulted in increased wait times or delays in scheduling timely medical appointments. For example, GAO identified clinics that did not use the electronic wait list to track new patients in need of medical appointments as required by VHA policy, putting these patients at risk for not receiving timely care. VA concurred with the four recommendations included in the report and, in April 2014, reported continued actions to address them. For example, in response to GAO's recommendation for VA to take actions to improve the reliability of its medical appointment wait time measures, officials stated the department has implemented new patient wait time measures that no longer rely on desired date recorded by a scheduler. VHA officials stated that the department also is continuing to address GAO's three additional recommendations. Although VA has initiated actions to address GAO's recommendations, continued work is needed to ensure these actions are fully implemented in a timely fashion. Ultimately, VHA's ability to ensure and accurately monitor access to timely medical appointments is critical to ensuring quality health care to veterans, who may have medical conditions that worsen if access is delayed.

section_title: Letter
paragraphs: I am pleased to be here today as you examine issues related to  challenges the Department of Veterans Affairs (VA) faces in providing  health care to our nation’s veterans. In recent years, VA’s Veterans  Health Administration (VHA) has faced a growing demand for providing  outpatient medical appointments. From fiscal years 2005 through 2012,  the number of annual outpatient medical appointments VHA provided  increased by approximately 45 percent, from 58 million to 84 million.  VHA provided this care through its primary and specialty care clinics,  which are managed by VA medical centers (VAMC). Although access to  timely medical appointments is critical to ensuring that veterans obtain  needed medical care, problems with VHA’s scheduling and management  of outpatient medical appointments may contribute to delays in care, or  care not being provided at all. Over the past few years there have been  numerous reports of VAMCs failing to provide timely care to patients,  including specialty care, and in some cases, the delays have resulted in  harm to patients. Nonetheless, VHA has reported continued  improvements in achieving timely patient access to medical  appointments. For example, in fiscal year 2011, VA reported that VHA  completed 89 percent of medical appointments for new patients within its  goal; in fiscal year 2012, VA reported that VHA completed 90 percent of  primary and specialty care new patient appointments within the goal.  However, in December 2012, we reported that VHA’s medical  appointment wait times were unreliable and VHA’s inadequate oversight  of the outpatient medical appointment scheduling processes contributed  to VHA’s problems with scheduling timely medical appointments.
When a physician or other provider determines that a veteran needs  outpatient specialty care, the provider refers the veteran to a specialist for  a clinical consult—a request for evaluation or management of a patient for  a specific clinical concern, or for a specialty procedure such as a  colonoscopy. VAMCs request and manage outpatient consults through an  electronic system that retains information about each consult request and  is part of VHA’s Veterans Health Information Systems and Technology  Architecture (VistA). reliable information on the status and outcomes of consults, and would  provide VHA information it needs to help effectively manage the process.  In 2012, however, VHA found that systemwide consult data could not be  adequately used to determine the extent to which veterans experienced  delays in receiving outpatient specialty care. As a result, in May 2013,  VHA launched an initiative to standardize aspects of the consult process,  with the goal of developing consistent and reliable information on consults  across all VAMCs.
VistA is the single integrated health information system used throughout VHA in all of its  health care settings. It contains patients’ electronic health records. schedulers to record appointments in VHA’s VistA medical appointment  scheduling system.
My statement today will draw from information we provided in a testimony  given on April 9, 2014, regarding VHA’s management of outpatient  specialty care consult processes at five selected VAMCs, and our  December 2012 report examining the reliability of VHA’s reported  outpatient medical appointment wait times data and scheduling  oversight. In particular, this statement highlights (1) preliminary  observations included in our April 9, 2014, testimony statement, and   (2) key findings and recommendations from our December 2012 report,  as well as the progress VHA has made in implementing those  recommendations.
The scope of our work is limited to outpatient consults; however, providers may also  request consults for inpatient care and administrative needs, among other things. providers of three high-volume specialty services—cardiology,  gastroenterology, and physical therapy. Additionally, for each of the five  medical centers, we reviewed the history of actions taken on a random  sample of 30 outpatient consults (10 from each of the three specialties  included in our review) that were requested during the period April 1,  2013, through September 30, 2013, that either took more than 90 days to  complete or had been in process for more than 90 days. The results of  our review of outpatient consults are not generalizable across all VAMCs.
For our December 2012 report examining the reliability of VHA’s reported  outpatient medical appointment wait times and scheduling oversight, we  reviewed VHA’s scheduling policy and methods for measuring medical  appointment wait times and interviewed VHA central office officials  responsible for developing them. We also visited 23 high-volume  outpatient clinics at four VAMCs selected for variation in size, complexity,  and location; these four VAMCs were located in Dayton, Ohio; Fort  Harrison, Montana; Los Angeles, California; and Washington, D.C. At  each VAMC we interviewed leadership and other officials about how they  manage and improve medical appointment timeliness, their oversight to  ensure accuracy of scheduling data and compliance with scheduling  policy, and problems staff experience in scheduling timely medical  appointments. We examined each VAMC’s and clinic’s implementation of  elements of VHA’s scheduling policy and obtained documentation of  scheduler training completion. In addition, we interviewed schedulers  from 19 of the 23 clinics visited, and also reviewed patient complaints  about telephone responsiveness, which is integral to timely medical  appointment scheduling. We interviewed the directors and relevant staff  of the four regional Veterans Integrated Service Networks (VISN) for the  VAMCs we visited. We also interviewed VHA central office officials and  officials at the VAMCs we visited about selected initiatives to improve  veterans’ access to timely medical appointments. Additionally, in April  2014, we reviewed documentation and interviewed officials from VHA’s  central office about the extent to which they have addressed the  recommendations we made in the 2012 report.
Our work for this statement, and the products on which it was based, was  conducted 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.
subsections: section_title: Background
paragraphs: When providers at VAMCs determine that a veteran needs outpatient  specialty care, they request and manage consults using VHA’s clinical  consult process. Clinical consults include requests by physicians or other  providers for both clinical consultations and procedures. A clinical  consultation is a request seeking an opinion, advice, or expertise  regarding evaluation or management of a patient’s specific clinical  concern, whereas a procedure is a request for a specialty procedure such  as a colonoscopy. Clinical consults are typically requested by a veteran’s  primary care provider using VHA’s electronic consult system. Once a  provider sends a request, VHA requires specialty care providers to review  it within 7 days and determine whether to accept the consult. If the  specialty care provider accepts the consult—determines the consult is  needed and is appropriate—an appointment is made for the patient to  receive the consultation or procedure. In some cases, a provider may  discontinue a consult for several reasons, including that the care is not  needed, the patient refuses care, or the patient is deceased. In other  cases the specialty care provider may determine that additional  information is needed, and will send the consult back to the requesting  provider, who can resubmit the consult with the needed information. Once  the appointment is held, VHA’s policy requires the specialty care provider  to appropriately document the results of the consult, which would then  close out the consult as completed in the electronic system. VHA’s  current guideline is that consults should be completed within 90 days of  the request.they were unable to complete the consult.
If an appointment is not held, staff are to document why  In 2012, VHA created a database to capture all consults systemwide and,  after reviewing these data, determined that the data were inadequate for  monitoring consults. One issue identified was the lack of standard  processes and uses of the electronic consult system across VHA. For  example, in addition to requesting consults for clinical concerns, the  system was also being used to request and manage a variety of  administrative tasks, such as requesting patient travel to appointments.  Additionally, VHA could not accurately determine whether patients  actually received the care they needed or if they received the care in a  timely fashion. According to VHA officials, approximately 2 million  consults (both clinical and administrative consults) were unresolved for  more than 90 days. Subsequently, VA’s Under Secretary for Health  convened a task force to address these and other issues regarding VHA’s  consult system, among other things. In response to task force  recommendations, in May 2013, VHA launched the Consult Management  Business Rules Initiative to standardize aspects of the consult process,  with the goal of developing consistent and reliable information on consults  across all VAMCs. This initiative requires VAMCs to complete four  specific tasks between July 1, 2013, and May 1, 2014:
Review and properly assign codes to consistently record consult  requests in the consult system;
Assign distinct identifiers in the electronic consult system to  differentiate between clinical and administrative consults;
Develop and implement strategies for requesting and managing  requests for consults that are not needed within 90 days—known as  “future care” consults; and
Conduct a clinical review as warranted, and as appropriate, close all  unresolved consults—those open more than 90 days.
At the time of our December 2012 review, VHA measured outpatient  medical appointment wait times as the number of days elapsed from the  patient’s or provider’s desired date, as recorded in the VistA scheduling  system by VAMCs’ schedulers. In fiscal year 2012, VHA had a goal of  completing new and established patient specialty care appointments  within 14 days of the desired date. VHA established this goal based on its  performance reported in previous years. To facilitate accountability for  achieving its wait time goals, VHA includes wait time measures—referred  to as performance measures—in its VISN directors’ and VAMC directors’  performance contracts, and VA includes measures in its budget  submissions and performance reports to Congress and stakeholders.  The performance measures, like wait time goals, have changed over  time.
Officials at VHA’s central office, VISNs, and VAMCs all have oversight  responsibilities for the implementation of VHA’s scheduling policy. For  example, each VAMC director, or designee, is responsible for ensuring  that clinics’ scheduling of medical appointments complies with VHA’s  scheduling policy and for ensuring that any staff who can schedule  medical appointments in the VistA scheduling system have completed the  required VHA scheduler training. In addition to the scheduling policy,  VHA has a separate directive that establishes policy on the provision of  telephone service related to clinical care, including facilitating telephone  access for medical appointment management.
section_title: GAO’s Preliminary Work Identified Examples of Delays in Specialty Care, and Limitations in VHA’s Implementation of Its Business Rules Impede Its Ability to Assess Delays
paragraphs: As we reported in our April 9, 2014, testimony statement, our preliminary  work identified examples of delays in veterans receiving requested   VAMC officials  outpatient specialty care at the five VAMCs we reviewed.cited increased demand for services, and patient no-shows and cancelled  appointments, among the factors that hinder their ability to meet VHA’s  guideline for completing consults within 90 days. Specifically, several  VAMC officials discussed a growing demand for both gastroenterology  procedures, such as colonoscopies, as well as consultations for physical  therapy evaluations. Additionally, officials noted that due to difficulty in  hiring and retaining specialists for these two clinical areas, they have  developed periodic backlogs in providing services. Officials at these  facilities indicated that they try to mitigate backlogs by referring veterans  for care with non-VA providers. However, this strategy does not always  prevent delays in veterans receiving timely care. For example, officials  from two VAMCs told us that non-VA providers are not always available.  Examples of consults that were not completed in 90 days include:
For 3 of 10 gastroenterology consults we reviewed for one VAMC, we  found that between 140 and 210 days elapsed from the dates the  consults were requested to when the patient received care. For the  consult that took 210 days, an appointment was not available and the  patient was placed on a waiting list before having a screening  colonoscopy.
For 4 of the 10 physical therapy consults we reviewed for one VAMC,  we found that between 108 and 152 days elapsed, with no apparent  actions taken to schedule an appointment for the veteran. The  patients’ files indicated that due to resource constraints, the clinic was  not accepting consults for non-service-connected physical therapy  evaluations. In 1 of these cases, several months passed before the  veteran was referred to non-VA care, and he was seen 252 days after  the initial consult request. In the other 3 cases, the physical therapy  clinic sent the consults back to the requesting provider, and the  veterans did not receive care for that consult.
For all 10 of the cardiology consults we reviewed for one VAMC, we  found that staff initially scheduled patients for appointments between  33 and 90 days after the request, but medical files indicated that  patients either cancelled or did not show for their initial appointments.  In several instances patients cancelled multiple times. In 4 of the  cases VAMC staff closed the consults without the patients being seen;  in the other 6 cases VAMC staff rescheduled the appointments for  times that exceeded the 90-day timeframe.
As we also reported, our preliminary work identified variation in how the  five VAMCs we reviewed have implemented key aspects of VHA’s  business rules, which limits the usefulness of the data in monitoring and  overseeing consults systemwide. As previously noted, VHA’s business  rules were designed to standardize aspects of the consult process, thus  creating consistency in VAMCs’ management of consults. However,  VAMCs have reported variation in how they are implementing certain  tasks required by the business rules. For example, VAMCs have  developed different strategies for managing future care consults— requests for specialty care appointments that are not clinically needed for  more than 90 days.
At one VAMC, officials reported that specialty care providers have  been instructed to discontinue consults for appointments that are not  needed within 90 days and requesting providers are to track these  consults outside of the electronic consult system and resubmit them  closer to the date the appointment is needed. These consults would  not appear in VHA’s systemwide data once they have been  discontinued.
At another VAMC, officials stated that appointments for specialty care  consults are scheduled regardless of whether the appointments are  needed beyond 90 days. These future care consults would appear in  VHA consult data and would eventually appear on a timeliness report  as consults open greater than 90 days. Officials from this VAMC  stated that they continually have to explain to VISN officials who  monitor the VAMC’s consult timeliness that these open consults do  not necessarily mean that care has been delayed.
Officials from another VAMC reported piloting a strategy in its  gastroenterology clinic where future care consults are entered in an  electronic system separate from the consult and appointment  scheduling systems. Approximately 30 to 60 days before the care is  needed the requesting provider is notified to enter the consult request  in the electronic consult system for the specialty care provider to  complete.
In addition, oversight of the implementation of VHA’s business rules has  been limited and has not included independent verification of VAMC  actions. VAMCs were required to self-certify completion of each of the  four tasks outlined in the business rules. VISNs were not required to  independently verify that VAMCs appropriately completed the tasks.  Without independent verification, VHA cannot be assured that VAMCs  implemented the tasks correctly.
Furthermore, VHA did not require that VAMCs document how they  addressed unresolved consults that were open greater than 90 days, and  none of the five VAMCs in our review were able to provide us with  specific documentation in this regard. VHA officials estimated that as of  April 2014, about 450,000 of the approximately 2 million consults (both  clinical and administrative consults) remained unresolved systemwide.  VAMC officials noted several reasons that consults were either completed  or discontinued in this process of addressing unresolved consults,  including improper recording of consult notes, patient cancellations, and  patient deaths. At one of the VAMCs we reviewed, a specialty care clinic  discontinued 18 consults the same day that a task for addressing  unresolved consults was due. Three of these 18 consults were part of our  random sample, and our review found no indication that a clinical review  was conducted prior to the consults being discontinued. Ultimately, the  lack of independent verification and documentation of how VAMCs  addressed these unresolved consults may have resulted in VHA consult  data that inaccurately reflected whether patients received the care  needed or received it in a timely manner.
Although VHA’s business rules were intended to create consistency in  VAMCs’ consult data, our preliminary work identified variation in  managing key aspects of consult management that are not addressed by  the business rules. For example, there are no detailed systemwide VHA  policies on how to handle patient no-shows and cancelled appointments,  particularly when patients repeatedly miss appointments, which may  make VAMCs’ consult data difficult to assess. For example, if a patient  cancels multiple specialty care appointments, the associated consult  would remain open and could inappropriately suggest delays in care. To  manage this type of situation, one VAMC developed a local consult policy  referred to as the “1-1-30” rule. The rule states that a patient must receive  at least 1 letter and 1 phone call, and be granted 30 days to contact the  VAMC to schedule a specialty care appointment. If the patient fails to do  so within this time frame, the specialty care provider may discontinue the  consult. According to VAMC officials, several of the consults we reviewed  would have been discontinued before reaching the 90-day threshold if the  1-1-30 rule had been in place at the time. Three VAMCs included in our  review also noted some type of policy addressing patient no-shows and  cancelled appointments, each of which varied in its requirements.  Without a standard policy across VHA addressing patient no-shows and  cancelled appointments, VHA consult data may reflect numerous  variations of how VAMCs handle patient no-shows and cancelled  appointments.
section_title: Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement, and VA Has Initiated Actions to Address Related GAO Recommendations
paragraphs: In December 2012, we reported that VHA’s reported outpatient medical  appointment wait times were unreliable and that inconsistent  implementation of VHA’s scheduling policy may have resulted in  increased wait times or delays in scheduling timely outpatient medical  appointments. Specifically, we found that VHA’s reported wait times were  unreliable because of problems with recording the appointment desired  date in the scheduling system. Since, at the time of our review, VHA  measured medical appointment wait times as the number of days elapsed  from the desired date, the reliability of reported wait time performance  was dependent on the consistency with which VAMC schedulers  recorded the desired date in the VistA scheduling system. However,  VHA’s scheduling policy and training documents were unclear and did not  ensure consistent use of the desired date. Some schedulers at VAMCs  that we visited did not record the desired date correctly. For example, the  desired date was recorded based on appointment availability, which  would have resulted in a reported wait time that was shorter than the  patient actually experienced.
At each of the four VAMCs we visited, we also found inconsistent  implementation of VHA’s scheduling policy, which impeded scheduling of  timely medical appointments. For example, we found the electronic wait  list was not always used to track new patients that needed medical  appointments as required by VHA scheduling policy, putting these  patients at risk for delays in care. Furthermore, VAMCs’ oversight of  compliance with VHA’s scheduling policy, such as ensuring the  completion of required scheduler training, was inconsistent across  facilities. VAMCs also described other problems with scheduling timely  medical appointments, including VHA’s outdated and inefficient  scheduling system, gaps in scheduler and provider staffing, and issues  with telephone access. For example, officials at all VAMCs we visited  reported that high call volumes and a lack of staff dedicated to answering  the telephones affected their ability to schedule timely medical  appointments.
VA concurred with the four recommendations included in our December  2012 report and reported continuing actions to address them.
First, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to improve the reliability of its  outpatient medical appointment wait time measures. In response,  VHA officials stated that they implemented more reliable measures of  patient wait times for primary and specialty care. In fiscal years 2013  and 2014, primary and specialty care appointments for new patients  have been measured using time stamps from the VistA scheduling  system to report the time elapsed between the date the appointment  was created—instead of the desired date—and the date the  appointment was completed. VHA officials stated that they made the  change from using desired date to creation date based on a study that  showed a significant association between new patient wait times  using the date the appointment was created and self-reported patient  satisfaction with the timeliness of VHA appointments. VA, in its FY  2013 Performance and Accountability Report, reported that VHA  completed 40 percent of new patient specialty care appointments  within 14 days of the date the appointment was created in fiscal year  2013; in contrast, VHA completed 90 percent of new patient specialty  care appointments within 14 days of the desired date in fiscal year  2012. VHA also modified its measurement of wait times for  established patients, keeping the appointment desired date as the  starting point, and using the date of the pending scheduled  appointment, instead of the date of the completed appointment, as the  end date for both primary and specialty care. VHA officials stated that  they decided to use the pending appointment date instead of the  completed appointment date because the pending appointment date  does not include the time accrued by patient no-shows and cancelled  appointments.
Second, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to ensure VAMCs consistently  implement VHA’s scheduling policy and ensure that all staff complete  required training. In response, VHA officials stated that the  department is in the process of revising the VHA scheduling policy to  include changes, such as the new methodology for measuring wait  times, and improvements and standardization of the use of the  electronic wait list. In the interim, VHA distributed guidance, via  memo, to VAMCs in March 2013 describing this information and also  offered webinars to VHA staff on eight dates in April and May of 2013.  To assist VISNs and VAMCs in the task of verifying that all staff have  completed required scheduler training, VHA has developed a  database that will allow a VAMC to identify all staff who have  scheduled appointments and the volume of appointments scheduled  by each; VAMC staff can then compare this information to the list of  staff that have completed the required training. However, VHA officials  have not established a target date for when this database would be  made available for use by VAMCs.
Third, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to require VAMCs to routinely  assess scheduling needs for purposes of allocation of staffing  resources. VHA officials stated that they are continuing to work on  identifying the best methodology to carry out this recommendation,  but stated that the database that tracks the volume of appointments  scheduled by individual staff also may prove to be a viable tool to  assess staffing needs and the allocation of resources. VHA officials  stated that they needed to discuss further how VAMCs could use this  tool, and that they had not established a targeted completion date for  actions to address this recommendation.
Finally, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to ensure that VAMCs provide  oversight of telephone access, and implement best practices to  improve telephone access for clinical care. In response, VHA required  each VISN director to require VAMCs to assess their current  telephone service against the VHA telephone improvement guide and  to electronically post an improvement plan with quarterly updates.  VAMCs are required to routinely update progress on the improvement  plan. VHA officials cited improvement in telephone response and call  abandonment rates since VAMCs were required to implement  improvement plans. Additionally, VHA officials said that the  department has also contracted with an outside vendor to assess  VHA’s telephone infrastructure and business process. In April 2014,  VHA officials stated that they expected to receive the first report in  approximately 2 months.
Although VA has initiated actions to address our recommendations, we  believe that continued work is needed to ensure these actions are fully  implemented in a timely fashion. Furthermore, it is important that VA  assess the extent to which these actions are achieving improvements in  medical appointment wait times and scheduling oversight as intended.  Ultimately, VHA’s ability to ensure and accurately monitor access to  timely medical appointments is critical to ensuring quality health care to  veterans, who may have medical conditions that worsen if access is  delayed.
Chairman Sanders, Ranking Member Burr, and Members of the  Committee, this concludes my statement. I would be pleased to respond  to any questions you may have.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: For further information about this statement, please contact   Debra A. Draper at (202) 512-7114 or draperd@gao.gov. Contact   points for our Offices of Congressional Relations and Public Affairs may  be found on the last page of this testimony. Key contributors to this  statement were Bonnie Anderson, Assistant Director; Janina Austin,  Assistant Director; Rebecca Abela; Jennie Apter; Jacquelyn Hamilton;  David Lichtenfeld; Brienne Tierney; and Ann Tynan.
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