VA Lacks Reliable Data on Medical Facilities’ Primary Care Panel Sizes and Does Not Have Effective Oversight Processes to Verify and Use Facilities’ Data to Monitor Primary Care Data Reported by VA Facilities on Primary Care Panel Sizes Are Unreliable

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. We found that  actual panel sizes across the six facilities varied from 23 percent below to  11 percent above their respective modeled panel size. 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. 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. VA’s panel management policy requires  facilities to ensure the reliability of their reported panel size data, but the  policy does not assign oversight responsibility to VA Central Office or the  networks for verifying the reliability of these data or for using the data for  monitoring purposes. Federal internal control standards state that  agencies should clearly define key areas of authority and responsibility,  ensure that reliable information is available, and assess the quality of  performance over time. Across the seven networks that oversee the seven selected facilities for  which we conducted a more in-depth analysis, we also identified  variations in the extent to which the networks verified facilities’ panel size  data and used the data to monitor and address panel sizes that were too  high or too low. Absent a robust oversight process that assigns responsibility, as  appropriate, to VA Central Office and networks for verifying facilities’  panel size data and using the data to monitor facilities’ management of  primary care—such as, examining wide variations from modeled panel  sizes—VA lacks assurance that facilities’ data are reliable and that they  are managing primary care panels in a manner that meets VA’s goals of  providing efficient, timely, and quality care to veterans. VA’s Encounter and Expenditure Data Show Wide Variation across Medical Facilities, and VA Central Office and Networks Do Not Use These Data to Monitor Primary Care

		Expenditures per Primary Care Encounter Varied Widely across VA Facilities

Based on our review of fiscal year 2014 VA-wide primary care  expenditure and encounter data, we found that expenditures per primary  care encounter varied widely across VA facilities, from a low of $150 to a  high of $396, after adjusting to account for geographic differences in labor  costs. Among other  things, this variation may indicate that primary care is being delivered  efficiently at facilities with relatively low expenditures per encounter or  inefficiently at facilities with relatively high expenditures per encounter. VA Central Office and Networks Verify and Use Facilities’ Encounter and Expenditure Data for Financial Purposes, But Not to Monitor Primary Care

While VA Central Office and networks verify and use facilities’ encounter  and expenditure data for financial purposes, VA’s policies governing  primary care do not require VA Central Office and networks to use these  data to monitor facilities’ management of primary care. Federal internal  control standards state that agencies need both operational and financial  data to determine whether they are meeting strategic goals and should  use such data to assess the quality of performance over time. Using panel  size data in conjunction with encounter and expenditure data, would allow  VA Central Office and networks to assess facilities’ capacity to provide  primary care services and the efficiency of care delivery. VA Central Office and the networks are also missing  opportunities to use readily available encounter and expenditure data to  potentially improve the efficiency of primary care service delivery. Recommendations for Executive Action

We recommend that the Secretary of the Department of Veterans Affairs,  direct the Undersecretary for Health to take the following two actions to  improve the reliability of VA’s primary care panel size data and improve  VA Central Office and the networks’ oversight of facilities’ management of  primary care:  Incorporate in policy an oversight process for primary care panel  management that assigns responsibility, as appropriate, to VA Central  Office and networks for (1) verifying each facility’s reported panel size  data currently in PCMM and in web-PCMM, if the software is rolled- out nationally, including such data as the number of primary care  patients, providers, support staff, and exam rooms; and (2) monitoring  facilities’ reported panel sizes in relation to the modeled panel size  and assisting facilities in taking steps to address situations where  reported panel sizes vary widely from modeled panel sizes. Review and document how to use encounter and expenditure data in  conjunction with panel size data to strengthen monitoring of facilities’  management of primary care.
Why GAO Did This Study

VA's 150 medical facilities manage primary care services provided to veterans. VA requires facilities to record and report data on primary care panel sizes to help facilities manage their workload and ensure that veterans receive timely and efficient care. VA also requires facilities to record and report data on primary care encounters and expenditures.
GAO was asked to examine these data and VA's oversight of primary care. This report examines (1) VA's panel size data across facilities and how VA uses these data to oversee primary care, and (2) VA's encounter and expenditure data across facilities and how VA uses these data to oversee primary care. GAO analyzed fiscal year 2014 data on primary care panel size, encounters, and expenditures for all VA facilities. GAO also conducted a more in-depth, nongeneralizable analysis of data and interviewed officials from seven facilities, selected based on geographic diversity and differences in facility complexity. GAO also interviewed VA Central Office and network officials to examine their oversight of primary care, including the extent to which they verify the data and use it to monitor the management of primary care.

What GAO Found

GAO found that the Department of Veterans Affairs' (VA) data on primary care panel sizes—that is, the number of patients VA providers and support staff are assigned as part of their patient portfolio—are unreliable across VA's 150 medical facilities and cannot be used to monitor facilities' management of primary care. Specifically, as part of its review, GAO found missing values and other inaccuracies in VA's data. Officials from VA's Primary Care Operations Office confirmed that facilities sometimes record and self-report these data inaccurately or in a manner that does not follow VA's policy and noted that this could result in the data reliability concerns GAO identified. GAO obtained updated data from six of seven selected facilities, corrected these data for inaccuracies, and then calculated the actual panel sizes for the six facilities. GAO found that for these six facilities the actual panel size varied from 23 percent below to 11 percent above the modeled panel size, which is the number of patients for whom a provider and support staff can reasonably deliver primary care as projected by VA. Such wide variation raises questions about whether veterans are receiving access to timely care and the appropriateness of the size of provider workload at these facilities.
Moreover, GAO found that while VA's primary care panel management policy requires facilities to ensure the reliability of their panel size data, it does not assign responsibility to VA Central Office or networks for verifying the reliability of facilities' data or require them to use the data for monitoring purposes. Federal internal control standards call for agencies to clearly define key areas of authority and responsibility, ensure that reliable information is available, and use this information to assess the quality of performance over time. Because VA's panel management policy is inconsistent with federal internal control standards, VA lacks assurance that its facilities' data are reliable and that the facilities are managing primary care panels in a manner that meets VA's goals of providing efficient, timely, and quality care to veterans.
In contrast to VA's panel data, GAO found that primary care encounter and expenditure data reported by all VA medical facilities are reliable, although the data show wide variations across facilities. For example, in fiscal year 2014, expenditures per primary care encounter—that is, a professional contact between a patient and a primary care provider—ranged from a low of $150 to a high of $396 after adjusting to account for geographic differences in labor costs across facilities. Such wide variations may indicate that services are being delivered inefficiently at some facilities with relatively higher per encounter costs compared to other facilities. However, while VA verifies and uses these data for financial purposes, VA's policies governing primary care do not require the use of the data to monitor facilities' management of primary care. Federal internal control standards state that agencies need both operational and financial data to determine whether they are meeting strategic goals and should use such data to assess the quality of performance over time. Using panel size data in conjunction with encounter and expenditure data would allow VA to assess facilities' capacity to provide primary care services and the efficiency of their care delivery. By not using available encounter and expenditure data in this manner, VA is missing an opportunity to potentially improve the efficiency of primary care service delivery.

What GAO Recommends

GAO recommends that VA verify facilities' panel size data, monitor and address panel sizes that are too high or too low, and review and document how to use encounter and expenditure data to help monitor facilities' management of primary care. VA agreed with GAO's recommendations and described its plans to implement them.