VA provides mental health services in each of its medical centers, which are located throughout VA’s 21 health care networks, in settings primarily used for providing mental health services. In these settings, which include mental health clinics, VA provides outpatient, residential, domiciliary, and inpatient hospital mental health services. (See table 1 for a description of VA’s mental health services.) The mental health services provided in these settings focus on rehabilitation- and recovery-oriented services to help patients with severe and persistent mental illnesses, including substance use disorders. VA also provides mental health services in VA settings that are not primarily used to provide mental health services, such as nursing homes (also referred to by VA as community living centers) and spinal cord injury clinics. Additionally, in some situations, VA pays for mental health services provided by non-VA providers in community settings. When there are no VA facilities near the veteran’s home or VA facilities are unable to provide certain mental health services on site, VA is authorized to enter into agreements with non-VA providers to provide these services. Specifically, VA facilities can make outpatient mental health services available from non-VA providers in the community who will accept VA payment— referred to as fee-basis care. In addition, VA facilities can contract with non-VA hospitals in the local community for inpatient hospital services— referred to as contract care. VA also provides counseling services that focus on mental health issues through VA Vet Centers. The counseling services to address mental health issues provided by Vet Centers differ from the mental health services provided by VA medical centers in that they focus on counseling to assist combat veterans in readjusting from wartime military service to civilian life. For example, the Vet Centers do not diagnose veterans’ mental health conditions. These counseling services provided by Vet Centers focus on a range of issues, including PTSD, drug and alcohol abuse, sexual trauma, and family issues. Veterans needing more acute care—for example, veterans with mental health co-morbidities such as severe PTSD and depression or those who pose a risk of harm to themselves or others—are often referred to VA medical centers for further evaluation and treatment. The number of Vet Centers has increased from 232 in fiscal year 2008 to 271 in fiscal year 2009. VA plans to increase the number of Vet Centers from 271 to 300 by the end of fiscal year 2011. VA reported in its fiscal year 2011 congressional budget justification spending about $4.4 billion in fiscal year 2009 on mental health services in VA settings primarily used for providing mental health services. However, VA had additional spending in fiscal year 2009—for mental health services provided in other settings—that VA did not report as mental health spending in its congressional budget justification or in any other publicly available report. In its fiscal year 2011 congressional budget justification, VA reported spending about $4.4 billion in fiscal year 2009 for mental health services provided in VA settings primarily used for mental health services. Outpatient services accounted for about 55 percent of this spending— about $2.4 billion—in fiscal year 2009. (See fig. 1.) VA reported spending the remaining $2 billion on inpatient hospital services—which provide intensive treatment for patients admitted to hospitals for mental health conditions—and on residential and domiciliary services, which provide rehabilitation, treatment, and a range of other services in a structured living arrangement at a VA facility. In fiscal year 2009, VA’s spending on mental health services provided in VA settings used primarily for mental health services varied across VA’s 21 networks, ranging from about $123 million in Network 19 (Denver) to about $297 million in Network 16 (Jackson). (See fig. 2.) Across VA’s networks, outpatient services accounted for the largest percentage of each network’s mental health spending in fiscal year 2009, followed by inpatient hospital services, though specific spending amounts varied by each network. According to VA officials, this variation may be caused, in part, by the number of inpatient mental health beds within a network. Networks with more beds would likely have higher utilization of inpatient hospital mental health services, resulting in higher spending for mental health services. VA officials told us that they do not have data to identify all the factors that account for the variations in spending for mental health services across networks. In addition to the $4.4 billion VA reported spending in fiscal year 2009 for mental health services provided in VA settings primarily used for mental health, VA spent additional amounts for mental health services. Specifically, VA (1) paid non-VA providers to provide mental health services in community settings; (2) provided mental health services through VA mental health providers in VA settings not primarily used for providing mental health services, such as nursing homes and spinal cord injury clinics; and (3) provided counseling services to address mental health issues through Vet Centers. However, VA did not report this spending as mental health spending in its fiscal year 2011 congressional budget justification or in any other publicly available report. VA determines how much it spends for some of these mental health services. According to VA officials, VA spent about $269.4 million in fiscal year 2009 for the following mental health services: VA spent about $137.4 million for non-VA providers—such as community- based hospitals and mental health professionals—to provide mental health services to patients. VA spent about $132 million on outpatient mental health services provided by mental health providers in VA settings not primarily used for providing mental health services. Although VA determines how much it spends for some of its mental health services, it did not report fiscal year 2009 spending for these mental health services as mental health spending in its fiscal year 2011 congressional budget justification or in any other publicly available report. Instead, according to VA officials, VA includes this spending as part of broader categories of spending when reporting information in congressional budget justifications. For example, VA’s reporting of outpatient care in its congressional budget justification includes part of VA’s spending for outpatient mental health services provided by non-VA providers in community settings. VA officials told us VA does not report its spending for mental health services provided by non-VA providers in community settings in its congressional budget justifications because determining this spending requires data that are not available at the time the congressional budget justification is published. In contrast to the mental health services for which VA determines how much it spends, there are other mental health services for which VA does not have spending information for fiscal year 2009. According to VA officials, VA does not have complete spending information for inpatient hospital mental health services provided by mental health providers in VA settings not primarily used to provide mental health services. Additionally, VA does not have spending information for counseling services to address mental health issues provided by Vet Centers. VA officials told us that VA does not determine how much it spends for these services for several reasons. For inpatient hospital mental health services, VA officials told us that it does not have cost information for about 25 percent of the services. According to VA officials, determining the costs for inpatient hospital mental health services is a new process and VA is currently determining these costs. For counseling services to address mental health issues provided by Vet Centers, VA officials told us that separating spending for these services from total Vet Center spending is difficult because most veterans receive multiple services—counseling and social support services, such as employment and legal support—from Vet Centers. In fiscal year 2009, VA provided mental health services to about 1.22 million unique patients in VA settings primarily used for providing mental health services. VA also provided mental health services through VA mental health providers in other VA settings, such as community settings for which VA paid non-VA providers to provide mental health services. However, VA did not report workload for all of its mental health services in its fiscal year 2011 congressional budget justification or in any other publicly available report. VA provided mental health services to about 1.22 million unique patients in fiscal year 2009 in VA settings primarily used for mental health services. (See table 2.) Almost all of these patients received outpatient services. VA officials said that this is primarily because patients receiving mental health services generally only need outpatient services and do not need the more intensive inpatient hospital and residential services. Inpatient hospital, residential, and domiciliary mental health services accounted for significantly smaller proportions of the total number of unique patients receiving mental health services in fiscal year 2009. In each of VA’s 21 networks, outpatient mental health services accounted for the largest percentage—more than 98 percent—of each network’s total number of unique patients receiving mental health services in fiscal year 2009. At the same time, the number of unique patients receiving outpatient services varied widely across the networks, from about 31,000 in Network 2 (Albany) to about 110,000 in Network 8 (Bay Pines). (See table 3.) There was also wide variation across the networks in fiscal year 2009 in the number of outpatient encounters. In addition, VA’s networks varied considerably in the number of unique patients receiving inpatient hospital services, with Networks 2 (Albany) and 8 (Bay Pines) being among the lowest and highest, respectively. (See table 4.) According to VA officials, network variations in the number of unique patients receiving mental health services may be due to enrollee population as well as other factors. For example, in fiscal year 2009, Network 2 (Albany) had the second lowest enrollee population, while Network 8 (Bay Pines) had the highest enrollee population among all networks. VA officials told us that they do not have data to identify all the factors that account for variations in workload for mental health services across the networks. VA’s 21 networks also varied widely in terms of the number of unique patients receiving residential and domiciliary mental health services in fiscal year 2009. For example, the number of unique patients receiving residential mental health services ranged from 0 in Network 22 (Long Beach) to about 1,400 in Network 12 (Chicago). (See table 5.) Network and other VA officials told us that these variations are in part due to the number of operating beds in each network. For example, VA officials told us that Network 22 (Long Beach) does not have any residential beds and that the network provides all of its residential services through agreements with non-VA providers and through its domiciliary services. VA did not report workload information for all of the mental health services it provided in fiscal year 2009 in its fiscal year 2011 congressional budget justification or in any other publicly available report. Specifically, VA did not report the total number of unique patients—1.22 million— receiving mental health services in fiscal year 2009 in the VA settings primarily used for providing mental health services. VA also did not report the number of unique patients receiving each type of service—inpatient hospital, residential, domiciliary, or outpatient—in these settings. Additionally, VA did not report the number of encounters for outpatient services in fiscal year 2009 in these settings. Instead, VA reported in its fiscal year 2011 congressional budget justification the total number of patients treated—the number of patients discharged during the year plus the number of patients remaining at the end of the year—for its inpatient hospital, residential, and domiciliary mental health services. VA officials told us that this measure—patients treated—would count a person with multiple admissions or discharges during the fiscal year multiple times. VA reports the total number of patients treated in its congressional budget justifications because this information is available at the time VA’s budget justification is published. The number of unique patients is not available until after VA’s budget justification is published. While VA reported the combined average daily census for inpatient hospital, residential, and domiciliary mental health services, it did not report the average daily census for each of these services. Further, VA did not report the average daily census for these services with the spending for these services in its budget justification, which VA does for some of its services. For example, for long-term care services, VA reporte average daily census and spending in the same table and reported averag daily census for both institutional and noninstitutional care in its fiscal VA officials said that VA year 2011 congressional budget justification. reported the combined average daily census for mental health services in its fiscal year 2011 congressional budget justification to be consistent its reporting of this information in previous budget justifications. Although VA did not report the number of encounters for outpatient mental health services provided in VA settings primarily used for providing mental health services, VA determines its workload for these mental health services using this measure. VA officials told us that this workload measure is a key measure that is relevant for measuring the workload for mental health services. In addition, VA did not report workload for the mental health services that it provided in other settings—community settings for which VA paid non- VA providers to provide mental health services and VA settings not primarily used for providing mental health services, such as nursing homes, in which VA mental health providers provided services. VA also did not report workload for counseling services to address mental health issues provided by Vet Centers. According to VA’s Mental Health Workload and Data Analysis Workgroup, any comprehensive review of mental health in VA should include the services delivered in these settings. According to the workgroup, VA’s ability to document the breadth and extent of its mental health services is key for ensuring that the resources for these services are used in the most productive and effective manner possible. Although VA did not report its total workload for mental health services provided in other settings in fiscal year 2009, VA determines its workload for some of these mental health services and was able to provide us with workload information for these services. According to VA officials, for fiscal year 2009: VA paid non-VA providers to deliver inpatient hospital mental health services in community settings to about 10,400 unique patients and outpatient mental health services to about 11,600 unique patients. The average daily census for the inpatient hospital services was about 250. The outpatient services accounted for about 130,000 encounters. VA provided mental health services in VA settings not primarily used for providing mental health services that accounted for about 485,000 encounters with mental health providers. According to VA’s mental health workload workgroup, the workload for mental health services provided in community settings by non-VA providers and in VA settings not primarily used for providing mental health services should be reported. The workgroup stated that the workload should not be reported with the workload for mental health services provided in settings that primarily provide mental health, but they should exist as a separate segment of any report. VA officials told us that while this workload information is not discretely identified as mental health in VA’s congressional budget justification, it is included as part of VA’s reporting of its workload for other services. VA officials said that VA has consistently focused its reporting of mental health services on those services provided in established mental health clinics. In contrast with the mental health services for which VA determines its workload, VA does not determine its workload for the counseling services to address mental health issues provided by Vet Centers. Similar to Vet Centers’ spending for these counseling services, according to VA officials, VA does not determine Vet Centers’ workload for counseling services to address mental health issues separately from Vet Centers’ total workload because of the difficulty associated in separating these counseling services from other services that veterans receive through Vet Centers. Nevertheless, VA officials estimated for us that Vet Centers provided counseling services to address mental health issues to about 70,000 veterans in fiscal year 2009, and these veterans accounted for about 989,000 visits for counseling services to address issues such as PTSD, drug and alcohol abuse, and family issues. According to VA’s mental health workload workgroup, Vet Centers’ workload for these services should be reported within the context of the mental health services they provide. VA uses its annual congressional budget justifications to provide its appropriations subcommittees and others with information on the department’s spending and workload for the medical services—such as mental health services—provided to eligible veterans in connection with appropriation requests. However, the information VA reported in its fiscal year 2011 congressional budget justification on its mental health services does not reflect VA’s total mental health spending and workload. In particular, VA did not report key workload information for mental health services provided in VA settings primarily used for providing mental health services. Specifically, VA did not report the number of encounters for outpatient services or the average daily census for each of its inpatient hospital, residential, and domiciliary services. Additionally, VA did not report the spending and workload for mental health services provided in other settings that are key to VA’s efforts to meet the mental health needs of veterans: VA settings not primarily used for providing mental health services and community settings where VA pays non-VA providers to provide mental health services. Although VA determines the amount it spends for some of these services, it did not report this information as mental health information in its fiscal year 2011 congressional budget justification or in any other publicly available report. Furthermore, VA does not determine and did not report spending and workload for the counseling services to address mental health issues provided by Vet Centers in its congressional budget justification or in any other publicly available report. VA’s reporting of mental health spending and workload does not give Congress a complete overview of VA’s mental health services and limits information available for congressional oversight. Reporting additional mental health spending and workload information could enhance information available for congressional oversight. To enhance information available for congressional oversight and use by stakeholders on VA’s spending and workload for mental health services, we recommend that the Secretary of Veterans Affairs take the following four actions: include workload information, including number of encounters and average daily census, by type of service, for mental health services provided in VA settings primarily used for providing mental health services with its presentation of mental health spending in its annual congressional budget justification; include spending and workload information, including number of encounters and average daily census, for mental health services that VA pays non-VA providers to deliver in community settings in its annual congressional budget justification, or in a separate, annual, publicly available report soon after the information becomes available; include spending and workload information, including number of encounters and average daily census, for mental health services provided in VA settings not primarily used for providing mental health services in its annual congressional budget justification, or in a separate, annual, publicly available report soon after the information becomes available; and include workload information, including number of visits, for counseling services to address mental health issues provided by Vet Centers in its annual congressional budget justification, or in a separate, annual, publicly available report soon after the information becomes available. We also recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to identify ways of incorporating spending information for Vet Center counseling services that address mental health issues in VA’s annual congressional budget justification or in a separate, annual, publicly available report soon after the information becomes available. We provided a draft of this report to VA for comment. In its written comments, reproduced in appendix II, VA concurred with three of our recommendations but did not concur with our recommendations related to Vet Center counseling services to address mental health issues. Specifically, VA concurred with our first recommendation to include workload information for mental health services provided in VA settings primarily used for providing mental health services with its presentation of mental health spending in its annual congressional budget justification. VA noted that it plans to provide this information in its fiscal year 2012 congressional budget justification. VA also concurred with our second and third recommendations to include spending and workload information for mental health services that (a) VA pays non-VA providers to deliver in community settings and (b) VA provides in settings not primarily used for providing mental health services in its annual congressional budget justification, or in a separate, annual, publicly available report soon after the information becomes available. VA noted that it would provide the spending and workload information publicly in a separate, annual, report by April 2011. VA did not concur with our recommendations related to Vet Centers’ reporting of spending and workload information for counseling services to address mental health issues. VA noted that Vet Centers provide a unique type of readjustment counseling that differs from the mental health services provided at VA medical centers, and that it is important not to report these activities as if they were traditional mental health activities. VA said that reporting Vet Center activities this way will detract from the structure that brings in many combat veterans and military sexual trauma clients and underreports the full scope of Vet Center activities. VA also said that because Vet Center workload and spending are intricately interwoven and directly aligned to the Vet Center, VA is unable to report one or the other independently within the traditional mental health services. We agree that Vet Centers provide a unique type of counseling that differs from the mental health services provided at VA medical centers, and have described differences between the two in this report. We have pointed out, for example, that Vet Centers do not diagnose mental health conditions, but instead provide counseling services to address mental health issues—such as PTSD and drug and alcohol abuse—as one of the services they provide. We believe that our recommendations related to Vet Centers could be implemented while addressing VA’s concerns. In this report, we are recommending that VA report Vet Center workload for counseling services to address mental health issues and identify ways of incorporating spending information for these services; not that Vet Center activities be reported as traditional mental health services. We believe that VA could report this information in a way that is consistent with the unique services Vet Centers provide and does not limit VA’s reporting of Vet Centers’ activities. Moreover, we believe that VA can provide workload data for Vet Center counseling services to address mental health issues separately from Vet Centers’ total workload. VA provided estimates included in this report for Vet Center workload, measured by visits, for counseling services to address mental health issues. Therefore, we believe that such information could be reported. Finally, we believe that reporting information on Vet Center spending and workload could enhance information available for congressional oversight and that this reporting could be done in a manner that maintains the distinction between services provided by Vet Centers and VA medical centers. We are sending copies of this report to the Secretary of Veterans Affairs. In addition, the report is available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. To examine the Department of Veterans Affairs’ (VA) spending and workload for mental health services, we examined, for fiscal year 2009, (1) VA’s spending for mental health services and (2) VA’s workload for mental health services. As part of this work, we examined VA’s reporting of its fiscal year 2009 spending and workload information in VA’s fiscal year 2011 congressional budget justification and whether VA reported this information in any other publicly available report. To examine VA’s spending and workload for mental health services that VA provided in VA medical centers and that VA paid non-VA providers to provide in community settings, we analyzed national- and network-level data for fiscal year 2009 obtained from the Veterans Health Administration Office of Finance. To examine VA’s workload for counseling services to address mental health issues that are provided by VA Vet Centers, we analyzed data obtained for fiscal year 2009 from the Veterans Health Administration’s Readjustment Counseling Service. Fiscal year 2009 spending data were not available for Vet Centers’ counseling services to address mental health issues. Fiscal year 2009 data were the most recently available spending and workload data at the time of our review. To help us understand how VA approaches mental health spending and workload, we also reviewed VA’s fiscal year 2008 spending and workload data, but we did not include these data in the report. For our analysis of VA mental health spending, we used obligations—VA’s cost of providing or paying for mental health services, including costs of administering mental health services, and national overhead, which includes the operating costs for VA headquarters, networks, and national programs. We used obligations because VA reports obligations for mental health services in its annual congressional budget submissions and VA officials told us they routinely determine VA’s spending for mental health services using obligations data. Our analysis of VA mental health spending does not include VA’s costs of providing medications for the treatment of mental health conditions. For our analysis of VA’s mental health workload in its medical centers, in community settings where VA pays non-VA providers to provide mental health services, and in Vet Centers, we used the following four workload measures: (1) unique patients—unduplicated count of patients receiving a particular type of service, (2) encounters— professional contacts between patients and providers for outpatient services, (3) visits—one or more professional contacts between a patient and a provider on a single day, and (4) average daily census—the average number of patients receiving inpatient hospital, residential, or domiciliary services on any given day during the course of the year. We chose these measures because VA officials told us that they are key measures that are relevant for measuring mental health workload. To examine variation in spending and workload we identified across VA’s networks, we conducted phone interviews with officials from a judgmental sample of four VA networks—Network 3 (Bronx), Network 8 (Bay Pines), Network 17 (Dallas), and Network 22 (Long Beach). We selected these networks based on variation in geographic location, mental health spending and workload, and the number of veterans enrolled in the network. We also visited VA’s Perry Point, Maryland, medical center to better understand how VA provides and pays for mental health services. We selected this medical center based on the range of mental health services it provides and the medical center’s proximity to Washington, D.C. We also interviewed officials from VA’s Veterans Health Administration Office of Finance, Readjustment Counseling Service, Office of Mental Health Services, Mental Health Enhancement Initiative for Primary Care, and Mental Health Workload and Data Analysis Workgroup. We interviewed these officials to obtain information on VA’s efforts to determine and report complete and accurate information on its spending and workload for mental health services. We also examined VA’s reporting of mental health spending and workload in its congressional budget justifications for fiscal years 2006 through 2011 and whether VA reported this information in any other publicly available report. We assessed the reliability of the national- and network-level data on VA’s spending and workload for mental health services in several ways. First, we checked for internal consistency of VA documents detailing VA’s spending and workload for mental health services for fiscal year 2009. Second, we compared the fiscal year 2009 spending and workload data we obtained from VA with the fiscal year 2009 mental health data VA reported in its fiscal year 2011 congressional budget justification. We also compared fiscal year 2009 spending and workload data with VA’s fiscal year 2008 spending and workload data. Third, we interviewed agency officials knowledgeable about VA’s mental health services and about VA’s mental health spending and workload data and the processes used to calculate them. We determined that the data we used in our analyses were sufficiently reliable for the purposes of this report. We conducted this performance audit from April 2009 through May 2010 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. In addition to the contact named above, James Musselwhite, Assistant Director; Janina Austin; Romuladus Azuine; Krister Friday; and Sarah Harvey made key contributions to this report.

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