Within VA Central Office, VHA’s Primary Care Services Office develops policies related to the management of primary care—including the recording and reporting of primary care panel size data—and VHA’s Primary Care Operations Office is responsible for executing policies related to primary care delivery and monitoring primary care. VHA’s Office of Finance develops policies related to the recording and reporting of primary care encounter and expenditure data. Each of VA’s 21 networks is responsible for overseeing the facilities within their network, and this responsibility includes overseeing facilities’ management of primary care. (See fig. 1.) Based on a review of studies, VA established a baseline panel size of 1,200 patients at any given time for a full-time primary care physician provider. The Primary Care Services Office adjusts the baseline panel size for each facility based on a model VA officials said they developed in 2003 that uses data reported by facilities—including data on the number of FTE providers, support staff, and exam rooms—and projections on the average number of primary care visits. These projections are based on patient characteristics, such as the proportion of patients with chronic conditions. VA refers to the adjusted baseline for each facility as the “modeled panel size,” which in fiscal year 2014 ranged from 1,140 to 1,338 across VA’s facilities. VA generally updates the modeled panel size annually for each facility. VA’s handbook on primary care management requires that facilities record and report primary care data using the Primary Care Management Module (PCMM) software. These data include the number of patients, FTE providers, support staff, and exam rooms, and the reported and modeled panel size. Each facility maintains its own PCMM software and is required to update its panel size data on an ongoing basis in PCMM, which electronically reports facilities’ data to a separate national database maintained by the Veterans Support Service Center. This national database allows the Primary Care Operations Office and VA’s networks to review the data. An encounter is a professional contact between a patient and a provider who has the primary responsibility for diagnosing, evaluating, and treating the patient’s condition. In addition to individual office visits, there are other types of encounters, such as telephone visits and group visits. Each facility identifies and tracks all of its expenditures associated with primary care encounters. Facilities transmit their encounter and expenditure data using the Decision Support System, which is maintained by the Office of Finance. This office is responsible for collecting and maintaining financial information for VA’s cost accounting—which identifies and assesses the costs of programs at the national, network, and facility levels—and for budgetary purposes. We found that VA lacks reliable data on primary care panel sizes across its facilities because the data that facilities record and report to VA Central Office and networks are sometimes inaccurate. Because reliable reported panel sizes were not available for all facilities, we calculated actual panel sizes at six of seven selected facilities and compared them to each facility’s modeled panel size for fiscal year 2014. We found that actual panel sizes across the six facilities varied from 23 percent below to 11 percent above their respective modeled panel size. Moreover, we found that VA Central Office and networks do not have effective oversight processes for verifying and using facilities’ panel size data to monitor facilities’ management of primary care. We found that VA lacks reliable data on primary care panel sizes across its 150 facilities because the data that facilities record in the PCMM software and report to the Primary Care Operations Office and to networks are sometimes inaccurate. Federal internal control standards state that reliable information is needed to determine whether an agency is meeting its goals for accountability for effective and efficient use of resources. However, our review of the reported panel size data for all of VA’s facilities for fiscal year 2014 revealed missing values as well as values that appeared to be unreasonably high or low, which raised concerns about these data. Officials from the Primary Care Operations Office, whom we interviewed about the reliability of these data, agreed that inaccuracies exist in the way facilities report data elements in PCMM, such as the number of patients assigned to primary care panels and the number of FTE providers, support staff, and exam rooms. Primary Care Operations Office officials pointed out that because the data are self- reported, facilities can and sometimes do record the data inaccurately or in a manner that does not follow VA’s policy on panel management. For example, the officials stated that some facilities may not count support staff and exam rooms as outlined in VA’s policy. These officials also stated that PCMM has limitations that may affect the reliability of facilities’ reported panel size data. For example, officials explained that the software makes it difficult for facilities to ensure that inactive patients (i.e., those who have not seen their primary care provider within the preceding two years or have died) are removed from providers’ panels. We identified similar inaccuracies in our more in depth review of panel size data reported by the seven selected facilities. Specifically, at three facilities we found inaccuracies in the reported number of FTE primary care providers and the reported number of patients, which impacted the facilities’ reported or modeled panel sizes. For example, the number of FTE primary care providers reported by one of these facilities was too low because the facility incorrectly recorded each FTE provider as only 90 percent of a FTE. We did not identify inaccuracies in the data reported by the remaining four facilities. (See table 1.) Because some medical facilities’ reported panel size data are unreliable, VA Central Office and network officials cannot readily determine each facility’s average primary care panel size nor compare these panel sizes to each facility’s modeled panel size to help ensure that care is being delivered in a timely manner to a reasonable number of patients. Moreover, having unreliable data can misinform VA in other aspects as well. For example, because VA’s model is based on historical data reported by facilities, unreliable data may result in VA’s modeled panel size being too high or too low for certain facilities. Also, if facilities are using unreliable data to manage their primary care panels—for example, using the data to assign patients to primary care providers—the facilities may be misinformed about the available capacity on primary care providers’ panels—information that is key to determining facilities’ staffing and other resource needs. Primary Care Operations Office officials told us that they intend to address data reliability issues over time. Specifically, the Primary Care Operations Office is in the process of implementing new software, called web-PCMM, which officials believe will address some concerns about the reliability of the data because the software features controls to help ensure that facilities record and report the data accurately and consistently. For example, web-PCMM will automatically remove inactive patients from providers’ panels. In preparation for the implementation of web-PCMM, Primary Care Operations Office officials said they have been training network and facility staff on the features and capabilities of the new software and instructing facility staff to review and correct their panel size data to help improve data accuracy. It is not yet known the extent to which the new software will actually address the data reliability issues because facilities will continue to self-report data. The Primary Care Operations Office started piloting the new software at selected facilities in 2014 and had planned to implement it agency-wide after resolving software interoperability issues identified during the pilot. However, officials said that implementation is currently on hold because of a lack of funding, and the officials could not provide an updated timeframe for its system-wide implementation. According to these officials, VA has spent about $8.8 million through July 2015 on the development and implementation of web-PCMM and requires an additional $1.5 million to implement it agency-wide. Because reliable data on reported panel sizes were not available for all of VA’s facilities at the time of our review, we calculated actual panel sizes at six of the seven selected facilities using updated data from these facilities and correcting for the inaccuracies we found at two facilities. We compared the actual panel size to each facility’s modeled panel size for fiscal year 2014. Although Primary Care Operations Office officials recommend that facilities keep panel sizes 10 to 15 percent below modeled panel sizes to accommodate growth and provider attrition, we found that actual panel sizes ranged from 23 percent below to 11 percent above their respective modeled panel size. This wide variation may indicate that actual panel sizes at some facilities are too low—potentially leading to inefficiency and wasted resources—or too high—potentially leading to veterans experiencing delays in obtaining care, among other negative effects. It may also indicate that VA’s modeled panel sizes are determined incorrectly based on unreliable facility data or do not sufficiently account for patient acuity levels and demand for primary care services. Actual average panel sizes across the six facilities ranged from a low of 1,000 patients per provider to a high of 1,338 patients per provider. (See fig. 2.) At the three facilities where actual panel sizes were the highest of the six for which we calculated the actual panel sizes, officials cited three key factors that contributed to the higher panel sizes. Growing patient demand: Officials at all three facilities stated that the growing number of patients seeking primary care services at their facilities has required them to assign a larger number of patients to each provider. Officials at one of these facilities stated that not assigning new patients to a panel would result in a greater number of walk-in patients seeking emergency care and a loss of continuity of care. Staffing shortages: Officials at all three facilities described difficulty recruiting primary care providers, which resulted in a shortage of providers. At one of these facilities, about 40 percent of primary care provider positions were vacant at the time of our review. Officials at all three facilities attributed recruiting difficulties to the rural location of these facilities, lack of academic affiliation of the facilities, and the lower pay that VA offers primary care providers compared to nearby private sector medical facilities. In addition, at one of these facilities, officials stated that non-compete clauses limited the facility’s ability to hire providers currently working in the private sector who might otherwise seek employment with VA.