Veterans' Health Care Budget: Improvements Made, but Additional Actions Needed to Address Problems Related to Estimates Supporting President's Request
Released: 2013-08-08T00:00:00

Letter

Background

VA provides health care services to various veteran populations— including an aging veteran population and a growing number of younger veterans returning from the military operations in Afghanistan and Iraq. VA operates approximately 150 hospitals, 130 nursing homes, 850 outpatient clinics, as well as other facilities to provide care to veterans. In general, veterans must enroll in VA health care to receive VA’s medical benefits package—a set of services that includes a full range of hospital and outpatient services, prescription drugs, and long-term care services provided in veterans’ own homes and in other locations in the community.

VA’s health care budget estimate includes both the total cost of providing VA health care services as well as estimates of anticipated funding from several sources. These sources include new appropriations, which refer to the appropriations to be provided for the upcoming fiscal year, and with respect to advance appropriations, the next fiscal year. For example, VA estimated it needed $54.6 billion in new appropriations for fiscal year 2014 and $55.6 billion in advance appropriations for fiscal year 2015. In addition to new appropriations, sources of funding include resources expected to be available from unobligated balances and collections and VA’s reimbursements that VA anticipates it will receive in the fiscal year. collections include third-party payments from veterans’ private health care insurance for the treatment of nonservice-connected conditions and veterans’ copayments for outpatient medications. VA’s reimbursements include amounts VA receives for services provided under service agreements with the Department of Defense (DOD).

In its budget justification, VA includes estimates related to the following:

Ongoing health care services, which include acute care, rehabilitative care, mental health, long-term care, and other health care programs.

In addition to new appropriations that VA may receive from Congress as a result of the annual appropriations process, funding may also be available from unobligated balances of multiyear appropriations, which remain available for a fixed period of time in excess of 1 fiscal year. For example, VA’s fiscal year 2013 appropriations provided that about $1.95 billion be available for 2 fiscal years. These funds may be carried over from fiscal year 2013 to fiscal year 2014 if they are not obligated by the end of fiscal year 2013. See Pub. L. No. 113-6, div. E, tit. II, § 226(b), 127 Stat. 198, 407 (2013).

Initiatives, which are proposals by the Secretary of VA, the President, or Congress to provide, expand, or create new health care services. Some of the proposed initiatives can be implemented within VA’s existing authority, while other initiatives would require a change in law.

Proposed savings, which are changes in the way VA manages its health care system to lower costs, such as changes to its purchasing and contracting strategies.

Collections and reimbursements, which are resources VA expects to collect from health insurers of veterans who receive VA care for nonservice-connected conditions and other sources, such as veterans’ copayments, and resources VA expects to receive as reimbursement of services provided to other government agencies or private or nonprofit entities.

Each year, Congress provides funding for VA health care through three appropriations accounts:

Medical Services, which funds health care services provided to eligible veterans and beneficiaries in VA’s medical centers, outpatient clinic facilities, contract hospitals, state homes, and outpatient programs on a fee basis.

Medical Support and Compliance, which funds the management and administration of VA’s health care system—including financial management, human resources, and logistics.

Medical Facilities, which funds the operation and maintenance of the VA health care system’s capital infrastructure, such as costs associated with NRM, utilities, facility repair, laundry services, and groundskeeping.

Advance appropriations for fiscal year 2014 for the three accounts were made in the following proportions: Medical Services at 80 percent, Medical Support and Compliance at 11 percent, and Medical Facilities at 9 percent.

In our prior work reviewing the President’s budget requests for VA health care services, we have reported on a variety of problems related to the reliability, transparency, and consistency of VA’s estimates and information included in its congressional budget justifications. In June 2012 we reported that in its fiscal year 2013 budget justification VA was not transparent about the agency’s fiscal year 2013 estimates for initiatives and ongoing health care services as well as VA’s estimate for initiatives in support of the fiscal year 2014 advance appropriations request. We also raised concerns regarding the reliability of VA’s fiscal year 2013 estimate for NRM, which did not address the long-standing pattern in which VA’s NRM spending has exceeded the agency’s estimates. VA concurred with a recommendation we made to improve the transparency of its estimates for initiatives and ongoing health care services, but did not concur with a recommendation related to the transparency of the agency’s initiative estimate in support of the advance appropriations request. VA also concurred with a third recommendation we made to improve the reliability of the agency’s NRM estimates. In September 2012 we also found that VA did not label health care services consistently in its budget justifications so that it was clear what services were being referred to across appropriations accounts. VA agreed with our recommendation to improve the consistency of the labels used for health care services. Most recently, in February 2013 we raised concerns about the reliability of VA’s estimates for non-NRM facility-related activities.estimates, and VA concurred with our recommendation.

VA Expanded the Use of the EHCPM to Develop Its Health Care Budget Estimate and Changed How It Reported Information on Certain Administrative Costs

VA Expanded the Use of the EHCPM by Using a Blend of EHCPM Estimates of Care Provided and Current Spending Data for Most Long-Term Care Services

VA expanded the use of the EHCPM by using estimates of the amount of care provided—which is known as workload—from the EHCPM to estimate resources needed for 14 long-term care services for fiscal years 2014 and 2015. VA included the 14 long-term care services in the EHCPM, but the agency did not use the estimates of needed resources developed for fiscal years 2014 and 2015 because, according to VA officials, the EHCPM expenditure estimates were determined to be too high to produce reliable estimates of needed resources in light of current expenditure data. As an alternative, the estimates for fiscal years 2014 and 2015 were based on the most current expenditure data available, as VA has done in prior years, and workload estimates from the EHCPM.

As a result of this blended approach, VA used the EHCPM, in part or in whole, to develop estimates for 74 health care services that accounted for more than 85 percent of VA’s budget estimate supporting the President’s fiscal year 2014 budget request for VA health care. This represents an increase compared to last year when VA used the EHCPM to estimate needed resources for 59 health care services, or approximately 78 percent of the agency’s fiscal year 2013 budget estimate. (See fig. 1.)

While the EHCPM accounted for a larger proportion of VA’s health care budget that supports the President’s budget request, revisions were made to the estimates developed by the EHCPM and other methods. As we have previously reported, these revisions resulted from the iterative and multilevel review process in VA and OMB and reflect the policy decisions and more current information, among other things.

VA Was Inconsistent in Reporting Certain Administrative Costs among Its Three Appropriations Accounts

Another change in VA’s fiscal year 2014 budget justification was how VA reported its estimate for certain administrative costs. In prior budget justifications, VA has reported its estimates for administrative personnel costs under “Administration” and estimates for administrative contracts under “Administrative Contract Services.” VA reported estimates for these administrative costs in each of the three appropriations accounts as well as for “Medical Care,” which reported the total costs for “Administration” and “Administrative Contract Services” across all three accounts. In its fiscal year 2014 budget justification, VA used a new budget category label—“Administrative Personnel”—when reporting estimated costs related to administrative personnel. VA also identified some of the costs reported under the new label by providing examples of the types of positions the agency considers administrative personnel, such as filing clerks, receptionists, police staff, chaplains, and other staff that are necessary for the effective operations of VA medical facilities.

However, VA did not consistently use the new “Administrative Personnel” label in its fiscal year 2014 budget justification. VA used the new label when reporting its Medical Care estimate for administrative personnel costs, but not when reporting the agency’s estimates for each of the three appropriations accounts. Instead, VA used the label “Administration,” even though the estimates reported under this label—$2.0 billion for Medical Services, $3.5 billion for Medical Support and Compliance, and $366 million for Medical Facilities—represented the same personnel costs in the estimate of $5.9 billion reported for “Administrative Personnel.” (See table 1.) VA officials explained that the use of “Administrative Personnel” was incorrect and that the “Administration” label will be used in future budget justifications. The inconsistency for reporting estimates for these costs may imply that VA used different labels to report estimates for different administrative costs. As such, the costs reported under these labels are unclear to Congress and other users of VA’s budget justification.

In addition to inconsistent labeling, VA also was not consistent in its reporting of information on the types of personnel positions included in the agency’s estimates for administrative personnel costs reported. VA provided information on the types of personnel positions included in the total estimate for administrative personnel costs under the budget category label “Administrative Personnel,” but did not provide similar information for the estimates for each appropriations account labeled under “Administration.” By not providing information on the types of positions included in these estimates, VA was not transparent about how the information that was provided applied to the estimates of administrative personnel costs in each of the appropriations accounts. For example, it is unclear to what extent police staff and chaplains will be funded across the three appropriations accounts.

Further, VA did not provide complete information on the costs included in its estimates for “Administrative Personnel” and “Administrative Contract Services.” Regarding its estimate for “Administrative Personnel” VA did not disclose that this estimate reflected other costs in addition to those costs associated with administrative personnel. According to VA officials, these other costs include those associated with administrative training programs and summer employment programs and are relatively small compared to the total estimate for “Administrative Personnel.” Regarding its estimates for “Administrative Contract Services” VA provided no information in its budget justification on the types of costs—which include contracts for maintenance of information technology and videoconferencing systems, management and professional services, laundry and dry-cleaning services, and janitorial services—reflected in the estimates. By not providing complete information on the costs included in its estimates for “Administrative Personnel” and “Administrative Contract Services,” VA was not transparent about all the costs reflected in these estimates. The lack of transparency regarding the costs included in its estimate of $5.9 billion for administrative personnel and its estimate of $2.3 billion for administrative contracts is inconsistent with the House Appropriations Committee’s recent request that more information on administrative costs be included in VA’s congressional budget justification and results in incomplete information for congressional deliberation.

Increase in the Request Compared to the Earlier, Advance Appropriations Request Reflected Changes VA Made to Supporting Estimates

The President’s fiscal year 2014 budget request for VA health care services was $54.6 billion, about $158 million more than the earlier, advance appropriations request for the same year. This increase came as a result of changes made to the estimate supporting the fiscal year 2014 request compared to the estimate for the advance appropriations request. Specifically, the President’s fiscal year 2014 request reflected an estimate of funding needed for initiatives that increased by $1.021 billion and an estimate for ongoing health care services that decreased by $519 million. This increase in the initiatives estimate was further offset by an estimate of $482 million in proposed savings from operational improvements and management initiatives, which resulted in a net increase in expected total obligations of $20 million. A decrease of $138 million in anticipated resources from collections and reimbursements with the increase in expected total obligations resulted in the net increase in the President’s request of $158 million. (See table 2.)

The following summarizes the changes in VA’s estimates resulting in the net change of $158 million: Increase in the estimated funding needed for initiatives. According to VA officials, as a result of the reduced estimate for ongoing health care services and the estimated savings from management initiatives and operational improvements, VA increased the estimate of funding needed for its initiatives to end homelessness among veterans, create new models of patient-centered care, and improve veteran mental health, among others. This estimate reflected funding needed for initiatives for which funding was not requested in the fiscal year 2014 advance appropriations request.

Decrease in the estimate for ongoing health care services. VA used updated assumptions and data in the EHCPM, which lowered its estimate for ongoing health care services. For example, VA updated its assumption for civilian employees’ pay in fiscal years 2013 and 2014 to account for the pay freeze which reduced the projected base salary of VA employees for these fiscal years and into the future. VA also used updated data from the most recently completed fiscal year to help ensure that its estimates better reflect current experience.

Increase in estimates of proposed savings from new acquisition savings and other initiatives. VA identified $482 million in estimated savings as a result of new initiatives, such as capping travel for VA employees at 2013 budgeted levels, and other operational improvements. These savings further reduced expected total obligations compared to the earlier advance appropriations request for fiscal year 2014.

Reduction in estimate for collections and reimbursements. The reduction in collections and reimbursements primarily reflected a decrease in the amount VA anticipated receiving from reimbursements, which include fees for services provided under service agreements with DOD. According to VA officials, the change to VA’s estimates for reimbursements was based on the use of more current data and the fact that VA no longer assumes it will be able to achieve reimbursement “recoveries” from prior fiscal years.

Steps Taken to Improve the Transparency, Consistency, and Reliability of Information and Estimates in VA’s Budget Justification

VA took steps to address, in varying degrees, five of the six problems we previously identified related to the reliability, transparency, and consistency of information in VA’s congressional budget justification. (See table 3.)

Specifically, VA took steps to address five of our six prior recommendations to improve estimates and information supporting the President’s fiscal year 2014 budget request:

Transparency for VA’s estimates for initiatives in support of the advance appropriations request. VA improved the transparency of its estimate for initiatives in support of the advance appropriations request by including a statement in the agency’s budget justification that indicated the estimate for initiatives did not reflect all the funding that may be required if the initiatives are to be continued. In June 2012, we reported that VA did not make it clear that part of the increase in its fiscal year 2013 initiatives estimate occurred because VA’s earlier estimate in support of the advance appropriations request did not include funding for all the initiatives the agency intended to continue.estimate for initiatives in support of the advance appropriations request by stating whether these estimates reflect all the funding that may be required if all initiatives are to be continued. Even though the agency did not concur with our recommendation, VA in its fiscal year 2014 budget justification stated that the final estimate for initiatives would be determined during the fiscal year 2015 budget process when updated data on initiatives were available. By clearly stating that its estimates for initiatives in support of the advance appropriations request will be addressed in the subsequent year’s budget process, VA provided new information relevant to understanding the estimates.

We recommended that VA improve the transparency of its

Consistency of language used to label health care services. VA improved the consistency of the language used to label health care services throughout its budget justification. In a September 2012 report, we found that VA used inconsistent labels when referring to the same health care services at different places in its fiscal year 2013 For example, VA referred to mental health budget justification.services as “psychiatric care” in the detailed presentation of the Medical Support and Compliance and Medical Facilities accounts and referred to the same services as “mental health” in the detailed presentation for the Medical Services account. We recommended that VA label health care services consistently so it would be clear which services were being referred to across appropriations accounts. VA concurred with our recommendation. In its fiscal year 2014 budget justification, VA used the same label for mental health, inpatient, and other services across all three appropriations accounts, which it had not previously done. In doing so, VA improved both the clarity and usefulness of the information included in its budget justification.

Reliability of estimates for non-NRM facility-related activities. VA improved the reliability of its estimates for non-NRM facility-related activities. In a February 2013 report, we found that lower than estimated spending for non-NRM facility-related activities, such as utilities and janitorial services, allowed VA to spend significantly more on NRM than it originally estimated in recent years. We recommended that VA determine why it has overestimated spending for non-NRM and use the results to improve future, non-NRM budget estimates. VA concurred with this recommendation. According to VA officials, the agency updated assumptions it used to predict growth for non-NRM facility-related activities in order to better reflect VA’s experience during the last 3 to 5 fiscal years. For example, in prior years, VA has estimated spending between $700 and $900 million on “Administrative Contract Services,” which was at least $360 million more than VA’s actual spending for this category. VA’s fiscal year 2014 estimate of $395 million for “Administrative Contract Services” appears to be a more reliable estimate of spending based on recent experience. By improving the reliability of information presented in its congressional budget justification regarding non-NRM facility-related activities, as we previously recommended, VA improved the usefulness of such information.

Reliability of estimates for NRM. According to VA officials, the agency also has taken steps to improve the reliability of its fiscal year 2014 NRM estimate. In June 2012, we reported that VA’s NRM spending has historically exceeded NRM estimates because these estimates have not consistently accounted for additional NRM spending by VA medical facilities. According to officials, VA’s estimate for NRM was based on a policy decision. We recommended that VA improve the reliability of its estimates for NRM by accounting for resources that VA medical facilities have consistently spent for this purpose. VA concurred with our recommendation. According to VA officials, the agency revised its method for estimating NRM and reduced its overall estimate of spending for the Medical Facilities account, which includes NRM. Specifically, VA officials indicated that the agency revised its method for estimating NRM to better account for expected spending. The resulting NRM estimate, combined with the previously discussed reduction in its non-NRM estimate, resulted in a decrease in estimated spending for VA’s Medical Facilities account. In prior years, additional NRM spending was the result of VA medical facilities using funds from the Medical Facilities account on NRM that were originally expected to be spent on other activities— such as utilities, grounds maintenance, and janitorial services. Reductions in the overall amount available from the Medical Facilities account would reduce the amount available for additional spending for NRM, so a decrease in VA’s overall estimate for its Medical Facilities account could potentially reduce the availability of additional resources for NRM beyond its fiscal year 2014 estimate.

Reliability of estimates for proposed savings. VA has taken steps to address some, but not all, of our prior concerns regarding the reliability of its estimates for proposed savings, which included savings from operational improvements and management initiatives. In a February 2012 report, we determined that some of the estimates for operational improvements included in VA’s fiscal year 2012 budget justification may not have been reliable estimates of future savings. We concluded that without a sound methodology VA ran the risk of falling short of its estimated savings, which may ultimately require VA to make difficult trade-offs to provide health care services with the available resources. We recommended that VA develop a sound methodology for estimating proposed savings from its operational improvements. VA concurred with the recommendation and officials told us during our prior review that the agency was working to address deficiencies in its methodology for estimating these savings. The information that we reviewed on VA’s methodology for estimating proposed savings for fiscal year 2014 to date confirmed that VA has taken some steps to address our prior concerns. For example, VA provided a basis for the assumptions used to calculate some of its proposed savings from acquisitions and employee travel. However, the information did not indicate that VA had fully implemented our recommendation for all operational improvements and management initiatives included in the estimates for proposed savings.

In regard to the sixth problem we identified, VA did not address a lack of transparency we previously found regarding its estimates for initiatives and ongoing health care services. In June 2012, we reported that VA did not disclose that it used a new reporting approach that combined both funding for initiatives and funding for certain ongoing health care services in its initiatives estimate. We recommended that VA improve the transparency of its estimates for initiatives and ongoing health care services by stating whether the estimates for initiatives included funding for ongoing health care services. VA concurred with our recommendation. According to officials, VA used the same reporting approach for initiatives in its fiscal year 2014 budget justification as the agency used in its fiscal year 2013 budget justification. However, we found no statement in the budget justification indicating this or more specifically whether the estimates for initiatives included funding for ongoing health care services. By not stating in its budget justification whether the estimates for initiatives included funding for ongoing health care services, VA was not transparent about the total amount of funding the agency may need in fiscal year 2014 for ongoing health care services that would require funding regardless of whether funding for certain initiatives continued.

Conclusions

In its congressional budget justification, VA provides Congress and other users with information on the agency’s health care budget estimate and other information that supports the policies and spending decisions represented in the President’s budget request. In response to our prior work, VA has taken steps to improve the consistency, reliability, and transparency of its estimates and information supporting the President’s budget request for VA health care. In particular, VA has taken steps to improve (1) the transparency of its estimates for initiatives in support of the advance appropriations request, (2) the consistency of its language used to label health care services, (3) the reliability of the estimates for other facility-related activities funded through the Medical Facilities account, (4) the reliability of its estimates for NRM, and (5) the reliability of proposed savings from operational improvements and management initiatives. However, VA did not indicate whether the estimates it reports for initiatives included funding needed for ongoing health care services, as we previously recommended. While VA has addressed to varying degrees the problems we previously identified, it is important that VA ensure that the recommendations from our prior work regarding the information and estimates in VA’s budget justification are fully implemented. Until these recommendations are fully implemented, the problems we previously identified will continue to limit the usefulness of related information to Congress and other users of VA’s budget justification.

In addition, our work shows that VA made key changes to its budget methodology—namely, VA used the EHCPM, in part, to develop estimates for most long-term care services. VA also changed how the agency reported its estimates for administrative costs, although VA did not do so consistently and comprehensively throughout its fiscal year 2014 budget justification. VA introduced a new budget category label “Administrative Personnel” for reporting its total estimate for administrative personnel costs, but used the old “Administration” label when reporting estimates for the same costs in each of VA’s three health care appropriations accounts. Additionally, VA defined some of the costs included in the “Administrative Personnel” label, but did not do so for “Administration” or “Administrative Contract Services” in its budget justification. This lack of transparency as well as the inconsistent labeling of administrative personnel costs results in unclear and incomplete information that limits its usefulness to Congress and other users of VA’s budget justification.

Recommendations for Executive Action

To improve the clarity and transparency of information in VA’s congressional budget justifications that support the President’s budget request for VA health care, we recommend the Secretary of Veterans Affairs take the following two actions: use consistent terminology to label estimates of administrative personnel costs and provide consistent and comprehensive information explaining the costs included in each budget category for administrative costs.

Agency Comments

We provided a draft of this report to VA and OMB for comment. In its written comments—reproduced in appendix I—VA generally agreed with our conclusions and concurred with our recommendations. In concurring with our first recommendation regarding terminology to label estimates of administrative personnel costs, VA stated that it will incorporate consistent terminology to label estimates for administrative and personnel costs in the fiscal year 2015 President’s budget request. In concurring with our second recommendation regarding information explaining the costs included in administrative costs, VA stated that it will provide consistent and comprehensive information explaining the costs included in each budget category for administrative costs in the fiscal year 2015 President’s budget request. OMB had no comments.

We are sending copies of this report to the Secretary of Veterans Affairs and the Director of the Office of Management and Budget, and appropriate congressional committees. In addition, the report will be available at no charge on the GAO website http://www.gao.gov.

If you or your staff have any questions about this report, please contact Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs are on the last page of this report. GAO staff who made major contributions to this report are listed in appendix II.

Appendix I: Comments from the Department of Veterans Affairs

Appendix II: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, James C. Musselwhite and Melissa Wolf, Assistant Directors; Kye Briesath, Krister Friday, Aaron Holling, Felicia Lopez, Lisa Motley, and Brienne Tierney made key contributions to this report.

Related GAO Products

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Veterans’ Health Care Budget: Better Labeling of Services and More Detailed Information Could Improve the Congressional Budget Justification. GAO-12-908. Washington, D.C.: September 18, 2012.

Veterans’ Health Care Budget: Transparency and Reliability of Some Estimates Supporting President’s Request Could Be Improved. GAO-12-689. Washington, D.C.: June 11, 2012.

VA Health Care: Estimates of Available Budget Resources Compared with Actual Amounts. GAO-12-383R. Washington, D.C.: March 30, 2012.

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Veterans Affairs: Issues Related to Real Property Realignment and Future Health Care Costs. GAO-11-877T. Washington, D.C.: July 27, 2011.

Veterans’ Health Care Budget Estimate: Changes Were Made in Developing the President’s Budget Request for Fiscal Years 2012 and 2013. GAO-11-622. Washington, D.C.: June 14, 2011.

Veterans’ Health Care: VA Uses a Projection Model to Develop Most of Its Health Care Budget Estimate to Inform the President’s Budget Request. GAO-11-205. Washington, D.C.: January 31, 2011.

VA Health Care: Spending for and Provision of Prosthetic Items. GAO-10-935. Washington, D.C.: September 30, 2010.

VA Health Care: Reporting of Spending and Workload for Mental Health Services Could Be Improved. GAO-10-570. Washington, D.C.: May 28, 2010.

Continuing Resolutions: Uncertainty Limited Management Options and Increased Workload in Selected Agencies. GAO-09-879. Washington, D.C.: September 24, 2009.

VA Health Care: Challenges in Budget Formulation and Issues Surrounding the Proposal for Advance Appropriations. GAO-09-664T. Washington, D.C.: April 29, 2009.

VA Health Care: Challenges in Budget Formulation and Execution. GAO-09-459T. Washington, D.C.: March 12, 2009.

VA Health Care: Long-Term Care Strategic Planning and Budgeting Need Improvement. GAO-09-145. Washington, D.C.: January 23, 2009.