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.