Section 107 of the Persian Gulf War Veterans' Benefits Act required VA to conduct a study to evaluate the health status of spouses and children of Persian Gulf War veterans. Under the study, VA was directed to provide diagnostic testing and medical examinations to any individual who (1) is the spouse or child of a veteran listed in VA's Persian Gulf War Veterans' Registry who is suffering from an illness or disorder; (2) is apparently suffering from, or may have suffered from, an illness or disorder (including a birth defect, miscarriage, or stillbirth) that cannot be disassociated from the veteran's service in the Southwest Asia theater of operations; and (3) in the case of a spouse, has granted VA permission to include relevant medical data in the Registry. These tests and examinations were to be used to determine the nature and extent of the association, if any, between the illness or disorder of the spouse or child and the illness of the veteran. The Congress authorized VA to use contractors to provide the medical examinations and specified that the amount spent for the program may not exceed $2 million. The entire $2 million was designated for examinations; the program administrative costs are to be covered by each coordinating medical center's operating budget. The act does not authorize funding for the treatment of family members of Persian Gulf veterans or reimbursement of participants for travel, lodging, or lost wages. The act stipulated that the program was to be carried out from November 1, 1994, through September 30, 1996. Program implementation was delayed until April 1996 because of a disagreement between VA and members of the Senate over the appropriate approach for establishing the program. VA proposed doing research, via the National Health Survey of Persian Gulf Veterans, which was designed to gather information on the incidence and nature of health problems occurring in Persian Gulf veterans and their families. The survey includes the examination of randomly selected Persian Gulf spouses and children as well as a control group, for comparison, of nondeployed Persian Gulf-era veterans and their families. (See app. II for a description of the National Health Survey of Persian Gulf Veterans.) However, in a November 1995 letter, the Ranking Minority Member of the Senate Committee on Veterans' Affairs and the Senate Minority Leader notified VA that its approach would not meet the mandate expressed in section 107 of the act. The letter stated that VA was expected to provide spouses and children the opportunity to seek medical examinations for conditions that family members believe are related to Persian Gulf service and to enter the examination information in the Persian Gulf Registry. The letter further stated that, while the survey was viewed as an important epidemiological study for which the Congress expressed approval by enactment of section 109 of the act, it would not meet the mandate of section 107 of the act. In response to these concerns, the Secretary of Veterans Affairs indicated in a February 1996 letter to the Ranking Minority Member of the Senate Committee on Veterans' Affairs that the Veterans Health Administration (VHA) would proceed immediately to provide voluntary examinations to Persian Gulf family members. VA initiated the Persian Gulf Spouse and Children Examination Program in April 1996 when it began accepting requests for clinical examinations. On October 9, 1996, the Veterans' Health Care Eligibility Reform Act of 1996 (P.L. 104-262) extended the program through December 31, 1998. The program is administered through VHA's Office of Public Health and Environmental Hazards and is implemented through coordinating VA medical centers established in each of VA's 22 Veterans Integrated Service Networks (VISN). The program is offered at 36 of VA's 172 medical centers. (See fig. 1 for a map showing locations of the VISNs and the 36 coordinating medical centers). Coordinating medical centers are responsible for establishing contracts, usually with their university-affiliated medical schools, for the examination of Persian Gulf spouses and children using standard medical protocols and guidelines developed by VA. The Persian Gulf Spouse and Children Examination Program has faced implementation problems that, to this point, have limited the program's effectiveness. To inform potential participants about the program, VA headquarters initiated national, broad-based outreach efforts with coordinating medical centers providing for local outreach. As of January 1998, VA coordinating medical centers have received 2,802 requests for examinations, but only 31 percent (872) of requested examinations have been completed. Factors contributing to the low completion rate include the lengthy and cumbersome process for scheduling examinations, which we found takes an average of 15 weeks from the time applicants first apply to the time examinations are completed. Also, examination sites are not easily accessible for some participants because only 36 of VA's 172 medical centers participate in the program, and the law does not allow for VA to reimburse participants for costs such as travel and lodging. In addition, as of January 1998, no examinations had been conducted in 3 of the 16 coordinating medical centers we contacted because those centers had not negotiated contracts with affiliated medical schools or other providers. Problems also existed with obtaining additional diagnostic testing in some locations. VA headquarters initiated national outreach through notices about the program in the Persian Gulf Review (a quarterly newsletter sent to about 67,000 Persian Gulf veterans in the Registry), public service television announcements, nationally broadcast television interviews with VA officials about Persian Gulf issues, and announcements on the Internet. The Office of Public Affairs, through its regional structure, provided coordinating VA medical centers with press releases about the program. All 172 VA medical centers received basic information about the Persian Gulf Spouse and Children Examination Program. Also, one nationwide teleconference, available to all VA medical centers, was held at the start of the program to encourage centers to inform veterans about the availability of free examinations for the family members of Persian Gulf veterans. According to a VA program official, local outreach was the responsibility of the 36 coordinating VA medical centers. Outreach efforts at the medical centers we contacted ranged from direct mailings to veterans on the Persian Gulf Registry to relying only on national outreach efforts. For example, the Tampa and Seattle medical centers contacted all veterans who had received Persian Gulf Registry examinations at their centers by letter or telephone. Some medical centers sent brochures to Persian Gulf veterans, and Persian Gulf coordinators visited reserve units and service organizations and informed them about the program. However, the Denver and Salt Lake City medical centers relied on national outreach efforts to provide program information. Without information on how participants learned of the program or knowledge of the potential universe of Persian Gulf spouses and children who believe their illnesses or disorders may be related to a family member's service in the Gulf, it is difficult to assess the effectiveness of national or local outreach efforts. However, VA estimated that, on the basis of the $2 million authorized for the program, it could provide about 4,500 examinations, based on an average cost of $400 per examination, and have a reserve of $200,000 to cover the cost of additional diagnostic tests. Examinations were offered on a first come, first served basis. As of January 1998, coordinating medical centers reported they had received 2,802 requests for examinations. By January 1998, about 7 percent ($148,916) had been expended from the $2 million allocated for the program. Eight hundred seventy-two examinations of spouses and children, 31 percent of examinations requested, had been completed as of January 1998. Forty-one percent of family members who requested examinations did not report for appointments, refused examinations, or had not yet responded to requests to schedule examinations, as shown in table 1. Several factors contribute to the low completion rate for requested examinations. For example, obtaining an examination requires several steps in a lengthy and cumbersome process. Individuals cannot contact a VA medical center to request an examination. Instead, requests for examinations are made by calling (toll free) the Persian Gulf War Veterans' Helpline. Next, Helpline staff forward requests to VA headquarters, which checks the VA and DOD Persian Gulf registries or the DOD Persian Gulf Deployment Listing to see if the veteran served in the Persian Gulf. VA headquarters then refers requests to one of the 36 coordinating VA medical centers to further establish eligibility. The medical center contacts the individual requesting the examination and asks him or her to provide a marriage certificate (for a spouse) or a birth certificate (for a child). Finally, the medical center sends the validated request to the affiliated medical school or provider, whose representative schedules an examination appointment with the requester. Our analysis showed that the process from requesting an examination to completion of the examination takes an average of over 15 weeks. According to a VA program official, the process for scheduling examinations was established as an efficient way to control, verify, and forward requests to the nearest coordinating medical center. Because the Persian Gulf Helpline already existed and operated 24 hours a day, it offered a means to monitor the number of requests received nationally. Also, Helpline staff were knowledgeable about a range of Persian Gulf issues and services available for veterans. Verification of veterans' service in the Persian Gulf is centrally administered because VA headquarters staff have access to the VA and DOD Persian Gulf registries and the Persian Gulf Deployment Listing. Verification of the child or spousal relationship is assigned to medical center staff who also provide a local VA contact and forward verified requests to examination providers to schedule appointments. Another major deterrent to obtaining examinations is the distance to examination sites or the accessibility of sites. VA implemented the program through 36 of its 172 medical centers. VA's Office of Public Health and Environmental Hazards issued a directive through the Chief Network VISN Office for each network to identify at least one medical center to participate in the program. All VISNs identified at least one coordinating medical center, 12 networks established two coordinating centers, and one VISN established three coordinating medical centers. A VA official stated that medical center decisions to participate in the program were based on the demographics of the Persian Gulf veteran population and the medical centers' ability to obtain contracts with their affiliated medical schools. Our analysis of the median distance between requesters' residences and the designated coordinating medical center showed that 48 requesters from Arizona were required to travel a median distance of 326 miles to the Albuquerque medical center to receive an examination. Our analysis also showed that 44 requesters from North Dakota, South Dakota, and Minnesota traveled a median distance of 219 miles for an examination in Minneapolis. According to a Washington, D.C., medical center official, family members considered the Georgetown University site to be inconvenient because it is not easily accessible by public transportation. Additional deterrents to obtaining examinations are lost income when taking time off from work and lack of reimbursement for travel and overnight lodging expenses. According to VA headquarters officials, enabling legislation would be necessary for VA to pay these expenses. VA decided to contract with affiliated medical schools where possible because established working relationships facilitated starting a program that had already been delayed. Program officials told us they were being flexible in also allowing medical centers to enter into agreements with managed care organizations or local physicians to examine family members in the absence of contracts with an affiliated medical school. However, no examinations were provided by 3 of the 16 coordinating medical centers we contacted--Augusta, Dayton, and Philadelphia--because they had not entered into agreements with their affiliated medical schools or other health care providers. Because Philadelphia was the only medical center participating in the program in VISN 4, no examinations had been given, as of January 1998, to the 88 family members who had requested examinations in the network. (See app. III for a table of coordinating medical centers and their affiliated medical schools.) VA headquarters officials were not aware that two of the three centers had not provided any examinations until we inquired about the program's status in January 1998. Because of turnover in key medical center positions, including program coordinators, VA officials indicated that they were unaware of the status of some requests for examinations. Also, VA did not require monthly activity reports from coordinating medical centers until October 1997--1-1/2 years after the start of the program. In addition, the headquarters program office lacks the capacity to validate information reported by medical center staff and has no line authority over field units that implement the program. In the December 1997 activity report, six of the coordinating medical centers had not submitted their information to headquarters. As a result, VA headquarters did not know the status of the program in terms of the number of applicants contacted, number of examinations given, and the number of coordinating medical centers that had active programs. After our inquiries, coordinating medical centers without active contracts with their affiliated medical schools were attempting to establish contracts with managed care organizations or private physicians, or were providing examinations in-house. For example, the Minneapolis VA medical center plans to provide examinations to women by using VA medical center staff from the Women's Clinic and to children by contracting with a local pediatrician. Additionally, the San Diego medical center contracted with a doctor with pediatric experience to conduct all of its examinations at a VA outpatient clinic. Women applicants receive additional tests from a VA nurse practitioner. Medical schools affiliated with the Denver and Minneapolis VA medical centers did not renew their contracts with VA because the volume of examinations was lower than expected and they were not paid in a timely manner. Other affiliated medical schools that still have contracts made similar complaints. For example, the Denver medical center told its affiliated medical school to anticipate conducting 200 examinations. However, only 54 requests for examinations were received, and the affiliated medical school ultimately performed only 16 examinations. In January 1998, the medical school received payment for 10 completed examinations that had been initially submitted for payment 9 months earlier in April 1997. We found that payment delays are caused, in part, because code sheets, which capture medical information for entry into the registry database, are rejected by VA's Austin, Texas, processing center when they are not properly completed. VA headquarters' guidance for establishing contracts stipulates that payment should be made only after satisfactory completion and submission to VA of all forms and code sheets. Staff from VA medical centers and affiliated medical schools complained that code sheets were difficult and time consuming to complete and lacked clear instructions. In addition, VA attempted to enter data into the registry using scannable code sheets. However, at one point, the program experienced a 100-percent rejection rate for code sheets because of problems with the scanning system. As a result, VA staff had to spend additional time correcting rejected code sheets. VA has since resorted to manually inputting the data. According to VA medical center officials, additional reasons for delayed payment include affiliated medical schools completing paperwork incorrectly, submitting untimely bills, and billing the wrong party. As of January 1998, of the 872 examinations completed, 541 examinations had been approved for payment. To conduct the examinations for spouses and children, VA developed a protocol that defines the standard tests and medical information collected during examinations. VA officials characterized the examination as a basic but complete physical. Adults receive diagnostic laboratory tests including blood count, blood chemistries, urinalysis, and, for women, a Pap smear. Children receive a physical examination and a medical history, including details on the development of symptoms. The children's protocol does not require routine diagnostic testing. Examination results are conveyed to family members with a form letter from the examining physician. If physicians determine that a referral to a medical specialist for additional diagnostic testing would be helpful to understanding a patient's symptoms, VA headquarters must give written approval if total examination and additional diagnostic testing costs exceed $400. At the locations we visited, examination costs ranged from $140 to $473. VA headquarters officials told us they approved all requests received for referrals to medical specialists--about 20. But officials at the Houston medical center said that although their examining physician requested only two referrals, she wanted to refer about 20 percent of those examined (47 patients) for additional diagnostic tests. However, these officials did not ask for additional referrals because they believed resources were constrained and the approval process would take additional time and require participants to make another trip to the medical school. On the other hand, the medical school affiliated with the Minneapolis medical center performed additional diagnostic tests without requesting approval. This strained the contractual relationship with the medical center because the medical school was not reimbursed for these additional tests. After more than 1-1/2 years of operation, VA has yet to fully implement the program to provide medical examinations to spouses and children of Persian Gulf veterans. Only 872 of the 2,802 requested examinations have been completed as of January 1998. Although a program of clinical examinations may not resolve issues related to whether illnesses among Persian Gulf family members are related to illnesses of veterans, the clinical examination approach provides Persian Gulf family members an opportunity to visit with a physician and to receive a free medical examination. Standardized examinations also give VA a health surveillance tool for cataloging prominent symptoms among Persian Gulf family members. The Persian Gulf Spouse and Children Program is scheduled to expire in December 1998. At the current rate of examinations, it is not likely that significant numbers of additional examinations will be completed by that date. If the Congress gives Persian Gulf family members the opportunity to be examined beyond December 1998, VA will need to seek ways to reduce barriers to participation, ensure that the necessary health care providers are available to provide examinations, and improve its capacity to monitor program implementation. If the Congress gives Persian Gulf family members the opportunity to be examined beyond December 1998, we recommend that the Secretary-designate of Veterans Affairs direct the Under Secretary for Health to simplify the process for requesting and scheduling examinations, offer examinations in more locations and seek approval to reimburse participants who are required to travel long distances to receive examinations, and enhance the capacity of the Office of Public Health and Environmental Hazards to monitor program implementation by field personnel. We provided a draft of this report to VA for comment, but VA did not provide comments in time to be included in this report. However, VA provided technical comments on March 19, 1998, which we incorporated where appropriate. As arranged with your offices, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after the date of this letter. At that time we will send copies of this report to the Secretary-designate of Veterans Affairs and interested congressional committees. We will also make copies available to others upon request. Please contact me on (202) 512-7101 if you or your staff have any questions concerning this report. Major contributors included George Poindexter, Brian Eddington, Jean Harker, Mike Gorin, and Alan Wernz. We obtained information for our review by visiting 8 of the 36 coordinating VA medical centers for the Persian Gulf Spouse and Children Examination Program in Chicago, Denver, East Orange, Houston, Minneapolis, Salt Lake City, Seattle, and Washington, D.C. We also contacted by telephone eight additional coordinating medical centers--Augusta, Birmingham, Dayton, Honolulu, Palo Alto, Philadelphia, San Diego, and Tampa. We selected these sites on the basis of their geographic mix, volume of examinations, and recommendations from VA and the Senate Committee on Veterans' Affairs. In some instances, medical school or clinic representatives were present during our visits. We telephoned some medical school representatives who were not present during site visits to obtain their views on the program and its implementation. Because of time constraints, we did not contact individual veterans or their family members. We interviewed officials at VA headquarters and the VA payment center located in Denver and also contacted the Office of Public Affairs concerning its outreach efforts. We reviewed reports on the status of contractual agreements, the number of examinations scheduled and completed, and the amount of funds disbursed for examinations. We analyzed data from VA's Austin data center (all 321 completed code sheets) and corresponding data from the Persian Gulf War Veterans' Helpline (requests for examinations that included the date the veteran or family member called) to determine the average length of time required to schedule and obtain an examination. We also analyzed data from the Persian Gulf Helpline to determine the distance to the nearest coordinating medical center for selected areas. We did not verify the accuracy of data received from either the Austin data center or the Persian Gulf Helpline. As agreed with your staffs, we did not evaluate the appropriateness of the survey instruments or medical evaluations used in the program. Initiated in July 1994, the National Health Survey of Persian Gulf Veterans is an epidemiological research study designed to estimate the prevalence of various symptoms and other health outcomes for Persian Gulf veterans and their families. The study is being conducted in three phases. In phase I, a questionnaire was mailed to each of 30,000 veterans (15,000 Persian Gulf veterans and 15,000 non-Persian Gulf veterans). In phase II, a sample of 8,000 nonrespondents was randomly selected for follow-up telephone calls to assess potential nonrespondent bias and to supplement the mailed survey data. In addition, during phase II, selected self-reported data collected during phase I was validated through records reviews for 2,000 veterans from each group. VA has completed the first two phases of this survey. In phase III, the same 2,000 veteran respondents and family members from each group will be invited to participate in a physical examination under a uniform comprehensive clinical examination protocol. VA is currently identifying 15 of its medical centers to examine veterans and family members over an 18-month period. The medical centers will be selected in a way that ensures a medical center will be within 3 to 4 hours driving time of the majority of the families sampled. Veterans will be examined at VA medical centers. The requested budget also permits up to half of the spouses and all of the children to be examined at affiliated medical schools. Veterans and spouses will be paid $200 per adult examination and $100 per child examination to compensate them for their time and inconvenience. Mileage or airfare, per diem, and lodging costs will be paid for families who live far enough away to require overnight stays. According to a VA official, these payments are allowable costs as part of this research project. The estimated report date for the survey is December 2000. Spouse: Evans Medical Foundation, Boston Medical Center Children: Child Health Foundation of Boston Spouse: Syracuse VA Medical Center Children: SUNY Health Science Center New Jersey University of Medicine and Dentistry No affiliated medical school contract No affiliated medical school contract University of Puerto Rico School of Medicine University of Tennessee Medical Group The Wilson Group, Vanderbilt University No affiliated medical school contract Wayne State University Medical School No affiliated medical school contract University of Missouri Health Science Center (continued) The first copy of each GAO report and testimony is free. Additional copies are $2 each. Orders should be sent to the following address, accompanied by a check or money order made out to the Superintendent of Documents, when necessary. VISA and MasterCard credit cards are accepted, also. Orders for 100 or more copies to be mailed to a single address are discounted 25 percent. 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Summary:
Pursuant to a congressional request, GAO reviewed the Department of Veterans Affairs' (VA) implementation of the Persian Gulf Spouse and Children Examination Program, focusing on: (1) outreach efforts; (2) obstacles to family members' participation; and (3) contracting issues. GAO noted that: (1) the Persian Gulf Spouse and Children Examination Program has faced numerous implementation problems that have limited its effectiveness in providing medical examinations; (2) to inform Persian Gulf veterans and their family members about the program, VA approached outreach in two ways--with a national campaign supplemented by local efforts at coordinating VA medical centers; (3) GAO found that some medical centers made efforts to contact Persian Gulf veterans and their families, while others relied on headquarters' outreach efforts; (4) however, GAO could not assess the effectiveness of these efforts because of a lack of information on the potential number of Persian Gulf family members who believe their illnesses are related to a family member's service in the Gulf War; (5) although as of January 1998 coordinating medical centers had received 2,802 requests for examinations, VA has completed only 872; (6) forty-one percent of applicants either failed to report for appointments, refused examinations, or had not yet answered requests to schedule examinations; (7) program participants face a lengthy and cumbersome scheduling process carried out through VA offices other than the local VA medical centers; (8) GAO's analysis showed that it takes an average of over 15 weeks for a participant to get an examination; (9) in addition, because VA chose to administer the program through only 36 of its 172 medical centers, examination sites are not always easily accessible to participants; (10) three of the 16 coordinating medical centers GAO contacted have not conducted any examinations because they have not contracted with their affiliated medical schools or other providers; (11) VA headquarters officials were unaware that examinations had not been conducted in two of the centers because of turnover in key center positions, and because VA did not start requiring monthly activity reports, which give the cumulative status of examination requests, from coordinating medical centers until October 1997; (12) GAO found that payment delays are caused in part by contractors incorrectly completing required paperwork, which staff from VA medical centers and affiliated medical schools told GAO is time consuming to complete and lacks clear instructions; and (13) although VA reserved $200,000 of authorized funds to cover the costs of tests, medical center officials told GAO they would have requested more referrals but believed resources were limited and the approval process would require additional time and travel for participants.