VA administers one of the largest health care systems in the United States and is charged, through the VHA, with providing health care services to the nation’s eligible veterans. VHA expects to provide care to more than 7 million veterans in fiscal year 2019 at health care facilities across the country through a system of 18 regional networks known as Veterans Integrated Service Networks. VHA has 172 medical centers that offer a variety of inpatient and outpatient services, ranging from routine examinations to complex surgical procedures. VHA’s health care system also includes community-based outpatient clinics and other facilities that generally limit services to primary care and some specialty care. When veterans need services that are not available at VHA medical facilities or within required driving distances or time frames, VHA may purchase care from non-VHA providers through one of its community care programs. VHA’s National Surgery Office is charged with overseeing the VA Organ Transplant Program, including the 12 VATCs that have established specialty services to provide solid organ transplant surgery and post- operative care, in some cases in conjunction with an academic affiliate. VATCs offer transplants for one or more organ types including heart, kidney, liver, and lung. (See fig. 1.) VHA considers transplant services provided through a VATC’s academic affiliate as care provided within the VA Organ Transplant Program. VHA’s National Surgery Office is responsible for clinical and operational oversight, as well as policies related to the VA Organ Transplant Program, including facilitating and monitoring the transplant referral process; overseeing quality of care; and monitoring outcomes of veterans receiving transplants. In 2013, VHA’s National Surgery Office established TRACER to track and monitor the referrals, evaluations, and outcomes for organ transplants performed at the VATCs. Referring VHA medical centers use the database to enter a referral for a veteran to be evaluated at a VATC; and VATCs use it to record referral reviews, patient evaluations, transplant outcomes, and follow-up care. In addition, the database provides the National Surgery Office with information used to monitor transplant volumes, the referral and evaluation process, and clinical outcomes across all VATCs. The VA Organ Transplant Program’s services include pre-transplant evaluation and testing, transplant surgery, post-transplant follow-up care, as well as transplant-related round-trip travel and lodging for both the veteran and a caregiver. VHA covers the cost of lodging for the veteran and caregiver through a variety of arrangements including contracts with local hotels and on-site VHA medical center housing, such as through the Fisher House Program. In addition, VHA may cover the cost of transplant services provided by non-VA providers; for example, when a veteran in urgent need of a heart transplant cannot travel to a VATC that provides that service. The VA MISSION Act includes provisions regarding VA’s authority to cover organ transplant services by non-VA providers—referred to as community care. Prior to the VA MISSION Act, VHA used its authority, as needed, to contract for transplant services with providers in the community when VHA care and services were not accessible in a timely fashion; however, the act provides additional authority to improve veterans’ access to transplant care and services through community providers, and authorizes transplant procedures with living organ donors who are not eligible for VHA care. On June 5, 2019, VA issued final regulations for the act. The Health Resources and Services Administration contracts with the United Network for Organ Sharing—a private, nonprofit organization—to manage the OPTN, which creates and maintains transplant policies and bylaws that are applicable to all transplant centers in the United States, including the VATCs and the academic affiliates performing transplants under contract with them. OPTN documents organ allocation policies, and collects and reports data on transplant recipients, donors, and outcomes. OPTN also conducts periodic audits of transplant program performance, including ensuring that transplant programs meet functional activity requirements (i.e., performing a minimum number of transplants in a proscribed period of time), and reviewing post-transplant patient survival rates. In addition, OPTN assesses whether transplant centers have established required quality assurance and performance improvement programs to help ensure the quality and safety of the transplant services provided. When transplant centers, including the VATCs, identify a candidate for organ transplantation, they register the patient in the OPTN’s centralized, national computer network that matches organ donors with transplant candidates, referred to in this report as the “national organ donation waitlist.” Veterans do not receive preference for organ allocation. When an organ becomes available, the computer network generates a list of transplant candidates ranked by a standard set of criteria that generally include factors such as blood and tissue type, size of the organ, medical urgency of the candidate, time on the waitlist, and geographic distance between the organ donor and transplant candidate. An organ procurement specialist then contacts the transplant program of the top-ranked transplant candidate to determine if the available organ is suitable for the candidate. If the organ is suitable, arrangements are made to procure, transport, and store the donated organ, and for the transplant candidate to travel to the transplant center for surgery. If the organ is not suitable for a given candidate, the procurement specialist contacts the transplant program of the next transplant candidate on the list until the organ is found to be suitable for a transplant candidate. Each year, VA allocates most of its appropriations for health care services to VHA’s 18 Veterans Integrated Service Networks through the Veterans Equitable Resource Allocation (VERA) system. VERA funds are allocated for general purposes, such as treatment for basic and complex patients, research and educational support, and equipment and maintenance costs; as well as for specific purposes, such as preventative and primary care initiatives and transplant care. The VERA model uses price groups— categories of veterans with similar resource needs based on the complexity of their medical conditions—to determine the funding level for each network. In addition, VHA’s National Surgery Office historically allocated transplant specific purpose funds to the VATCs for solid organ transplants, because the costs of transplant services were not fully covered by general purpose funds. Beginning in fiscal year 2019, the VERA model was modified to establish a new price group specifically for transplant patients, allowing full funding with general purpose funds for these services. VHA officials explained that this change is expected to reduce the need for specific purpose funds to supplement transplant care. VHA officials told us academic affiliate contracts are funded through the medical services appropriations allocated to the VHA medical center where the VATC is located. To receive an organ transplant in the VA Organ Transplant Program, a veteran must go through a five-step process: (1) initial referral, (2) pre- operative evaluation, (3) listing on the OPTN national organ donation waitlist, (4) transplant surgery, and (5) follow-up care that continues for the remainder of the veteran’s life. See figure 2 for an overview of the five steps. Step 1: Initial screening and referral. A veteran seeking an organ transplant begins the process by having an initial screening at a referring VHA medical center. If VHA medical center providers determine that the veteran is a potential candidate for an organ transplant, they may prepare a formal referral to a VATC. To prepare a referral, the providers use an organ-specific checklist and other tools developed by VHA’s National Surgery Office with input from other experts in the field to perform a standard set of assessments of the veteran’s clinical, social, and mental health status. In addition, VHA officials told us that the initial screening includes an assessment of the veteran’s social and family support; for example, identifying a caregiver who can accompany and stay with the veteran throughout the transplant process. In addition, there are organ- specific criteria, such as negative tobacco smoking screens for veterans seeking a heart transplant, and up-to-date dialysis information for liver and kidney transplant candidates. VHA officials noted that the providers may consult with staff at a VATC as needed during the initial screening phase. Following the initial screening, if VHA medical center providers determine that the veteran is a potential candidate for a transplant, they enter the checklist information into the TRACER database, include the results of the required assessments outlined in the checklist, and attach any additional medical information, such as testing performed through care in the community. VHA officials told us that the VATC to which the veteran is referred is chosen based on factors including distance from the veteran’s home and the types of organ transplants offered at the VATC. Once the VHA medical center completes a referral in TRACER, the information becomes available to the selected VATC. Step 2: VATC referral review and veteran evaluation. When the VATC receives a veteran’s referral, VATC staff review it to determine whether the referral information is complete and the veteran meets the criteria to continue the process. If so, VATC staff evaluate the veteran and perform additional testing and clinical preparation needed to determine whether the veteran is a transplant candidate. To reduce the travel burden on veterans and their caregivers, providers at the veteran’s referring VHA medical center may arrange for telehealth visits with the VATC for pre- transplant education and consultation. However, travel for in-person appointments at the VATC is required for most veterans referred for evaluation. According to VATC officials we spoke with, the VATC considers the severity of the veteran’s illness and overall need for a transplant. In some cases, this assessment is conducted by a panel of experts composed of VATC providers and providers from the academic affiliate, where applicable. For example, some VATCs hold regular review meetings to discuss cases up for consideration jointly with providers from the VHA medical center and the academic affiliate, because individual cases may be co-managed depending on the type of organ being transplanted and the services provided at an individual VATC. Providers at some VATCs provide care at both the VATC and its academic affiliate, allowing for integrated clinical management of patients. If the VATC determines the veteran is not a candidate for transplantation, the referring VHA medical center can request a second opinion by another VATC. If the veteran is once again determined not to be a candidate, the referring VHA medical center can make a final appeal. Appeals are forwarded to the VA’s Transplant Surgical Advisory Board, comprised of subject matter experts, for consideration. According to VHA policy, the board considers the appeal and makes a recommendation to the National Director of Surgery (the head of VHA’s National Surgery Office) who is responsible for facilitating second opinion requests, making the final determination, and notifying the referring VHA medical center regarding the final appeal determination. VHA reported that between fiscal years 2014 and 2018, 39 decisions were appealed to the Transplant Surgical Advisory Board, one of which was approved for resubmission to another VATC for consideration. Step 3: Listing on the national organ donation waitlist. If the VATC determines that the veteran is a candidate for an organ transplant, VATC staff add the veteran to the national organ donation waitlist. At this point in the process, veterans follow the same procedure as the general population seeking an organ transplant. To maximize the chances that the veteran will receive an organ, the VATC staff may also discuss options the veteran can pursue for personally identifying a potential living donor (if applicable for the organ needed). VATC officials noted that they may provide other clinical interventions to help prolong a veteran’s life and preserve his or her health while awaiting an organ; for example, implanting a ventricular assist device into a veteran awaiting a heart transplant. Step 4: Transplant surgery. According to VATC officials, once a veteran is placed on the OPTN national organ donation waitlist, depending on the type of organ needed, the veteran and their caregiver may be required to travel to the VATC and remain in close proximity while awaiting organ availability. In some cases, such as for a liver transplant, a harvested organ can be kept viable for longer periods, allowing time for a veteran to travel from their home to the VATC once the organ becomes available. Depending on the arrangement between a particular VATC and its academic affiliate, the veteran could receive the transplant surgery and post-operative care at either the VATC or the affiliate. For example, the VATC in Richmond performs heart transplants and contracts with its affiliate for liver transplants. The VATC in Nashville performs kidney transplants and contracts with its affiliate for heart and liver transplants. From fiscal years 2014 through 2018, 61 percent of the transplant surgeries provided within the VA Organ Transplant Program were performed by a VATC and 39 percent were performed by an academic affiliate. See table 1 for a list of VATCs, organ types transplanted, and contracts with academic affiliates. Step 5: Follow-up care. Following the transplant surgery and the immediate post-operative care provided by the VATC and its academic affiliate, the veteran receives on-going follow-up care from both the VATC and the referring VHA medical center. VHA providers monitor veterans post-transplant for the remainder of their lives; for example, to oversee post-transplant immunosuppression, and track survival rates and outcomes for organ recipients. VA policy states that the VATC has primary responsibility for providing care while the veteran is at the VATC for the transplant and for providing specialized follow-up care after the veteran is discharged. In general, however, following discharge from the VATC, the veteran’s referring VHA medical center maintains responsibility for the veteran’s care coordination. VHA has policies and processes to allow for some aspects of transplant- related care, including follow-up care, to be done via telehealth—that is, visits with a VATC provider remotely from the veteran’s referring VHA medical center. VHA medical centers may establish telehealth agreements with VATCs to ease the burden of travel for veterans and their caregivers, and to allow for ongoing monitoring of the veteran’s health post-transplant. Because VHA monitors transplant recipients for the rest of their lives, using telehealth can decrease the need for the veteran to travel back to the VATC unless a specific clinical need arises, such as biopsies for heart transplant recipients. VHA officials noted that follow-up care is facilitated by VA’s shared electronic health record, which allows VHA providers to share medical records and other patient information over time and across locations. Further, VHA providers noted that follow-up care and communication between VATCs and primary care teams can be more complicated in the private sector when transplant services are not generally part of a patient’s whole system of care. VATCs provided about 1,700 organ transplants between fiscal year 2014 and fiscal year 2018. The number of organ transplants provided each year generally increased, ranging from 300 transplants in fiscal year 2014 to a peak of 400 transplants in fiscal year 2017. During this 5-year period, kidneys and livers were the most frequently transplanted organs, representing 85 percent of all organs transplanted at VATCs. Heart and lung transplants were much less common and represented the remaining transplants. (See fig. 3.) For the programs that were active during all 5 years from fiscal year 2014 through fiscal year 2018, the number of solid organ transplants performed varied by VATC, ranging from 12 at the Birmingham VATC to 399 at the Pittsburgh VATC. (See table 2.) The nearly 1,700 transplants performed through the VA Organ Transplant Program represent a relatively small portion—less than 20 percent—of the VHA referrals for organ transplant between fiscal years 2014 and 2018. While thousands of veterans are referred for solid organ transplants, far fewer veterans ultimately receive transplants. According to VA officials, VHA considers all submitted transplant referrals; however, many patients do not meet initial screening criteria to proceed with a formal evaluation. For example, a veteran’s state of illness may not be severe enough to warrant a full transplant evaluation. Further, some veterans who are offered transplant evaluations decide not to proceed following education about the process. Officials noted that in many cases, the transplant evaluation reveals that a veteran does not meet the criteria for a transplant, such as not having a committed caregiver who can support the veteran through the evaluation and transplant procedure. Of the veterans who are listed on the national organ donation waitlist, VHA officials report that the number of transplants is limited by the supply of organs, which does not meet the demand in the U.S. general population, including veterans. For veterans who received an organ transplant from a VATC between fiscal year 2014 and fiscal year 2018, survival rates varied by organ type, with the 3-year survival rate ranging from about 95 percent for kidney transplants to 85 percent for lung transplants, according to National Surgery Office data. (See table 3.) For national-level general population survival rates, see appendix II. Consistent with the increase in the number of organ transplants provided between fiscal years 2014 and 2018, VHA’s allocations and spending for transplant services also increased, similarly peaking in fiscal year 2017. VHA funds these services using a combination of general purpose and specific purpose funds. VHA’s National Surgery Office allocates transplant specific purpose funding to the VATCs based upon the transplant-related workload the VATCs report through TRACER. See appendix III for additional information on transplant-related allocations and expenditures. VHA Allocation of Transplant Specific Purpose Funds. VHA allocated $292 million in transplant specific purpose funds during this 5-year period, ranging from $50.3 million in fiscal year 2014 to approximately $64.6 million in fiscal year 2018. (See table 5 in app. III.) Transplant specific purpose funds are used to support program overhead costs (infrastructure and maintenance) associated with organ transplants performed at VATCs. In addition, they are used for pre-transplant evaluations, lodging, and some miscellaneous costs associated with transplants, such as living donor evaluations. Further, transplant specific purpose funds are used to fund other VHA medical centers without a VATC that perform certain transplant follow-up care. VHA Expenditures for Transplant-Related Services VHA Expenditures of General Purpose and Specific Purpose Funds for Veterans Receiving a Solid Organ Transplant. VHA spent approximately $259 million for services provided to veterans who received a solid organ transplant at a VATC during this 5- year period, ranging from $44.6 million in fiscal year 2014 to a high of $57.7 million in fiscal year 2017. Similarly, VHA’s spending for pre- and post-transplant care provided at VHA medical centers totaled approximately $68.6 million during this time, ranging from $10.8 million in fiscal year 2014 to $15.6 million in fiscal year 2017. (See tables 6 and 7 in app. III.) VHA Contracts with VATC Academic Affiliates. VHA spent over $216 million on contract payments to academic affiliates for transplant services during this period, ranging from $34.9 million in fiscal year 2014 to a high of $49.9 million in fiscal year 2017. This increased spending corresponded to an increase in the number of transplants performed by academic affiliates, which totaled 669 transplants—nearly 40 percent of all VATC transplants from fiscal year 2014 through fiscal year 2018. The highest volume—146 transplants—and the highest cost—$49.9 million—occurred in fiscal year 2017. (See table 8 in app. III.) VHA Contracts for Community Care. From fiscal year 2014 through fiscal year 2018, VHA spent $7.9 million for solid organ transplant services provided to 53 veterans through community care programs. (See table 9 in app. III.) According to VHA data, over this 5-year period, 50 of these transplants were authorized using title 38 U.S.C. § 1703 (“Non-VA Medical Care Program”). The remaining three were funded using the Veterans Access, Choice, and Accountability Act of 2014 (Choice Act)—totaling approximately $411,000 of the $7.9 million. VA has reported that while the Choice Act allows VHA to provide an eligible veteran transplant care at a transplant center in the community, generally at Medicare rates, organ procurement is only partially covered at Medicare rates. This has resulted in community providers being less willing to provide transplant services for VHA patients through community care programs. From fiscal years 2014 through 2018, VATCs received 10,494 referrals from VHA medical centers. In that time, the percentage of VATC referrals that met timeliness standards outlined by VHA’s National Surgery Office improved. Stable condition referrals: For veterans in stable condition, VHA requires that VATCs review referrals and decide within 5 business days whether veterans are potential candidates for an organ transplant and should receive a full evaluation. The percentage of referrals for which VATCs met the timeliness standard increased from 95 percent in fiscal year 2014 to 99 percent in fiscal year 2018. Emergency condition referrals: For veterans in emergency circumstances, VHA requires that VATCs review referrals and document within 48 hours whether veterans are potential transplant candidates and should receive a full evaluation. The percentage of referrals for which VATCs met the timeliness standard increased from 94 percent in fiscal year 2014 to 98 percent in fiscal year 2018. (For more information, see app. IV.) National Surgery Office officials identified two possible drivers of the observed improvements: (1) increased monitoring, and (2) providing real- time feedback to VATCs through TRACER. Providers at one VATC noted that they use information from the National Surgery Office’s Transplant Quarterly Reports to identify areas to improve and they assigned a transplant team nurse the responsibility to monitor program quality, including that timeliness requirements are being met. A provider at a VATC where timeliness has improved since fiscal year 2014 and is now at 100 percent explained that his facility has provided training to staff at referring VHA medical centers they work with frequently. For example, the official said he has hosted a workshop for transplant coordinators to provide training on submitting transplant referral packets through TRACER. While VATCs almost always met timeliness standards in fiscal year 2018, VATC officials in our review noted that transplant coordinators at referring VHA medical centers sometimes submit referral packets that are incomplete, requiring additional time and effort by the provider to search for information not readily available and potentially adding delays to the VATC review times. VHA requires that a complete referral packet be submitted through TRACER using a referral progress note that contains the required assessments outlined in the organ-specific checklist. The referral packet can also include attachments to transmit some required information, such as results for tests performed by community providers. Providers at three VATCs told us that reviewing a complete referral packet generally takes 30 minutes to an hour. However, in cases where the packet is incomplete (for example, it does not include the results from all the required assessments) the process is much less efficient and, according to two providers we interviewed, can take up to 5 hours. VATC providers explained that when not all test results are available in the referral packet, they have to access another VHA medical center’s electronic medical record system and search for the required information. Accessing another medical center’s system adds time to the referral review process and can take time away from the provider’s other duties, such as providing follow-up care to transplant patients or monitoring transplant outcomes. Internal controls state that management should assign responsibility to discrete units and demonstrate a commitment to develop competent individuals in those units, such as through training, to enable the organization to operate in an efficient manner and help achieve the organization’s objectives. However, a lack of understanding or implementation of the required information needed in the referral packets can make the process for reviewing the referral packets inefficient in some cases. Specifically, one VATC provider told us that incomplete referral packets are often due to a lack of training for staff at the referring VHA medical centers on the process for submitting referrals through TRACER. In fact, four of the five transplant coordinators at referring VA medical centers we interviewed reported a lack of training on submitting transplant referrals through TRACER. Instead, for example, a transplant coordinator at one referring VHA medical center said she received assistance from a medical clerk at her facility on how to submit referrals through TRACER. Officials at VHA’s National Surgery Office told us that although there is no centralized, in-person training available for referring VHA medical centers, the office published a training guide, which is available on VA’s intranet and provides guidance on how to access TRACER and refer patients for transplant evaluation. Despite this resource, transplant coordinators from some referring VHA medical centers still cited a need for additional training or other guidance. For example, one official said training for new transplant coordinators would be helpful as would regular updates on transplant criteria or policy changes, such as through regular calls or a newsletter targeted at transplant coordinators. In addition to timeliness requirements for referral review, VHA requires that VATCs complete an evaluation of veterans within 30 calendar days of receiving a referral to determine whether they are a candidate for transplant and should be placed on the national organ donation waitlist. From fiscal years 2014 through 2018, VATCs increased the percentage of evaluations completed within this time frame, from 55 percent (576 of 1,045 appointments) in fiscal year 2014 to 89 percent (1,193 of 1,346 appointments) in fiscal year 2017, before dropping to 87 percent (1,325 of 1,521 appointments) in fiscal year 2018. National Surgery Office officials attributed the overall improvement to increased monitoring and the increased availability of telehealth for conducting transplant evaluations. See appendix IV for more information on the timeliness of transplant evaluations by VATCs from fiscal years 2014 through 2018. The extent to which delayed evaluations occurred varied by VATC location and by organ type each fiscal year. For example, in fiscal year 2018, we found that the average time from referral to completed evaluation was less than 30 days for 19 of the 20 organ transplant programs, and overall, 13 percent of evaluations were not completed within 30 days. Of note, 51 of 128, or 40 percent, of evaluations for kidney transplant at the Bronx VATC were completed more than 30 days after the referral was submitted, with evaluations ranging from 5 to 84 days after submission. In contrast, all 69, or 100 percent, of liver evaluations at the Nashville VATC were completed within 30 days, with evaluations ranging from 0 to 28 days after the referral was submitted. (See fig. 4.) According to VHA data and three VATC providers we interviewed, evaluation appointment availability is not a cause for delays in most cases; rather, delays are primarily due to veteran preference. According to VHA data for 1,617 evaluation appointments completed in fiscal year 2018, 1,412 appointments were scheduled within the 30-day requirement. For the remaining 205 appointments, 13 were delayed due to lack of appointment availability, and 192 appointments were delayed due to veteran preference. According to providers at the three VATCs we interviewed, while veterans may prefer to be seen at a later date for a number of reasons, including that their caregiver is not available to travel, veterans are not always aware that they should be evaluated within 30 days of being referred for a transplant. VHA requires the referring VHA medical center to discuss the 30 day evaluation requirement with the veteran prior to submitting the referral. According to VHA, in some cases evaluation timeliness is a critical factor affecting patient outcomes. Although a veteran may choose to be seen at a time beyond the 30-day standard, postponing an evaluation may delay their placement on the national organ donation waitlist, potentially having a negative impact on their health and well-being. Officials at five VATCs and two referring VHA medical centers reported that additional training for transplant coordinators would be helpful for improving evaluation timeliness. Additional training enables employees to develop competencies and reinforce requirements, which is consistent with internal control standards that state that management should develop competent individuals to achieve the entity’s objectives. According to one VATC provider, transplant coordinators at referring VHA medical centers should be trained to discuss travel with the veteran before submitting the referral, so the transplant coordinator and the veteran understand that the evaluation should be completed within 30 days of referral, increasing the likelihood that veterans will be able to schedule timely evaluations. A referring VHA medical center transplant coordinator also said that additional training about the VATC’s processes would be helpful in order to be better able to inform veterans and their caregivers about what to expect from the transplant process. Placing veterans on the national organ donation waitlist as soon as possible is critical for potential transplant candidates to be matched with a donor organ. Since fiscal year 2014, VHA has improved timeliness for reviewing transplant referrals to determine if a veteran is a candidate and for completing transplant evaluations. However, VHA medical center staff do not always submit complete transplant referral packets through TRACER, which can create inefficiencies and delay the referral review process. Similarly, inefficiencies in the transplant evaluation process occur when VATC and VHA medical center staff do not fully inform veterans of their role in the transplant evaluation process, specifically, that their evaluation be completed within 30 days of referral. Without additional training to address these inefficiencies a veteran’s placement on the national organ donation waitlist could be delayed. The Under Secretary for Health should establish a requirement that VHA’s National Surgery Office provide additional training to staff at referring VHA medical centers on (a) submitting referral packets through TRACER that are complete, and (b) understanding and communicating the veteran’s role in the evaluation process related to the timely completion of transplant evaluations. (Recommendation 1) We provided a draft of this product to VA for comment. In its comments, reproduced in appendix V, the department concurred in principle with our recommendation, reiterated the resources it currently makes available to staff at referring VHA medical centers, and described actions it plans to take to address the recommendation. Specifically, VHA’s National Surgery Office plans to distribute a memorandum to all VHA facilities to reinforce the available training and resources to support the staff at referring VHA medical centers with submitting complete referrals, and to ensure adequate communication of the veteran’s role in timely completion of transplant evaluations. VA also provided technical comments, which we incorporated as appropriate. In addition, we provided a draft of this report to the Department of Health and Human Services for review and they did not have any comments. We are sending copies of this report to the appropriate congressional committees, the Secretary of VA, the Secretary of the Department of Health and Human Services, and other interested parties. In addition, the report is available at no charge on GAO’s website at http://www.gao.gov/. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or silass@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix VI. Appendix I: Department of Veterans Affairs Transplant Centers Providing Solid Organ Transplants (printable) We analyzed national transplant survival rates by organ type using data from the Scientific Registry of Transplant Recipients. All transplant facilities across the United States, including Department of Veterans Affairs transplant centers, provide data to this database. Table 4 shows the national transplant survival rates by organ for fiscal years 2014 through 2018. Annually, the Department of Veterans Affairs (VA) allocates most of its appropriations for health care services to the Veterans Integrated Service Networks within the Veterans Health Administration (VHA) through a model called the Veterans Equitable Resource Allocation (VERA). The VERA model is designed to fund patient care based on a methodology that develops set, or “capitated,” rates for different groups or categories of veterans with similar resource needs based on the complexity of their medical conditions. Categories include oncology, visual impairment, chronic mental illness, and critical illness. VERA uses a national formula that considers the number of veterans and the complexity of care provided; and certain geographic factors, such as local labor costs, in determining how much each Veterans Integrated Service Network should receive. VERA determines this amount based on each network’s activities and needs in the following areas: patient care, equipment, nonrecurring maintenance, education support, and research support. The networks, in turn, allocate resources to their respective VHA medical centers, including those with VA transplant centers (VATC). The networks distribute VERA funds to VHA medical centers based on the complexity of patients treated at the medical center in previous fiscal years. This appendix provides VA’s reported allocations and expenditures for solid organ transplant services through its VATCs and contracts with academic affiliates and community providers from fiscal year 2014 through fiscal year 2018. Table 5 shows VHA allocation of transplant specific purpose funds by VATC for transplant-related services. Table 6 shows VHA expenditures at each VATC for veterans who received solid organ transplants. Table 7 shows VHA expenditures for pre- and post-transplant services provided by VHA medical centers without a VATC for veterans who received transplants. Table 8 shows the total number of transplants and contract payments to academic affiliates for solid organ transplant services. Table 9 shows total number and spending for solid organ transplants provided by community care providers. The Veterans Health Administration (VHA) has timeliness requirements for reviewing transplant referrals to determine whether veterans are potential candidates for organ transplant and should receive a full evaluation, and for completing timely evaluations for potential candidates. Timeliness of referral reviews improved from fiscal year 2014 through fiscal year 2018. VHA requires that for veterans in stable condition, Department of Veterans Affairs transplant centers (VATC) review referrals and decide within 5 business days whether veterans are potential candidates for an organ transplant and should receive a full evaluation. For emergency cases, VATCs should perform this review and document the results within 48 hours. Table 10 shows the number of referrals reviewed and the percentage of timely referrals for each VATC and organ transplant program from fiscal year 2014 through fiscal year 2018. VHA requires that VATCs complete an evaluation of stable veterans within 30 calendar days of receiving a referral to determine whether they are a candidate for transplant and should be placed on the national organ donation waitlist. The percentage of evaluations completed within the required time frame increased from 55 percent in fiscal year 2014 to 87 percent in fiscal year 2018, although some variation can be seen by organ type and location within each fiscal year. Table 11 shows the number of completed evaluations and the percentage of timely evaluations for each VATC and organ transplant program from fiscal year 2014 through fiscal year 2018. In addition to the contact named above, Marcia A. Mann (Assistant Director), Jill K. Center (Analyst-in-Charge), Colin Ashwood, Emily Binek, Emily Bippus, Shana Deitch, Keith Haddock, and Ebony Russ made key contributions to this report. Also contributing were Krister Friday, Jacquelyn Hamilton, Giselle Hicks, Drew Long, Vikki Porter, and Ethiene Salgado-Rodriguez.

Summary: As of June 2019, over 113,000 people in the United States—including veterans—were waiting for an organ transplant. In 2018, more than 36,000 organ transplants were performed at transplant centers across the country, including those within the Department of Veterans Affairs' (VA) Organ Transplant Program. GAO was asked to review how VA administers and oversees its organ transplant program. This report, among other things, examines the process and timeliness with which VA reviews referrals and completes evaluations for organ transplants. GAO reviewed data from VHA's Transplant Referral and Cost Evaluation Reimbursement database, documents related to VA's transplant program, and federal internal control standards. GAO conducted site visits to three of the 12 VATCs, selected to obtain diversity in geography and types of organs transplanted. At the selected VATCs, GAO reviewed facility data and documents related to organ transplants and interviewed officials. GAO also collected and reviewed information from the remaining nine VATCs. The 12 Veterans Affairs' transplant centers (VATC), which are overseen by the Veterans Health Administration (VHA), almost always met the referral timeliness standard from fiscal years 2014 through 2018. When a veteran is determined to be a potential candidate for an organ transplant, he or she can receive a formal referral to a VATC. Depending on the type of referral, the VATC must meet specific timeliness standards for reviewing the referral and deciding if the veteran should receive a full evaluation. Likewise, VATCs have timeliness standards for conducting the full evaluation, and generally showed improvement in meeting that standard from fiscal years 2014 through 2018. For those delays in conducting full evaluations that did occur, GAO found they varied by organ type and VATC. Specifically, in fiscal year 2018, transplant evaluation timeliness ranged from 60 percent at two VATC kidney programs to 100 percent at kidney, liver, heart or lung programs across seven different VATCs. According to VATC officials, transplant evaluation delays are caused when patients or caregivers are not available or not aware that they are required to be evaluated within 30 days of being referred. Although veterans may prefer to be seen at a later date, untimely evaluations can delay veterans' placement on the national organ donation waitlist. According to VHA data, 192 of the 1,617 transplant evaluation appointments completed in fiscal year 2018 did not meet the 30-day requirement. VATC officials said this was because veterans were not available or not aware of the requirement. GAO found that staff at referring VHA medical centers lacked a full understanding of the transplant referral and evaluation process. For example, VATC providers told GAO that transplant referrals are sometimes incomplete, requiring providers to spend extra time searching for information that should have been readily available. GAO found that additional training for medical center staff would help to improve the efficiency of the transplant referral process and the timeliness of transplant evaluations provided to veterans, a critical factor affecting veteran outcomes. VHA should provide additional training for staff at VHA medical centers that refer patients for organ transplants on (1) submitting complete referrals and (2) understanding and communicating the veteran's role related to timely completion of transplant evaluations. VA concurred in principle with the recommendation and described actions the department will take to address the recommendation.