1.) Since the first community-based outpatient clinic was established by VHA’s Amarillo Medical Center in 1994, VHA has approved a total of 198 community-based clinics. In addition, VHA provided guidance to networks for developing proposals—which were to provide more details than the original white papers—and implemented a process to help networks develop more consistent and thorough proposals, in accordance with VHA’s guidelines. Toward this end, VHA stated that it is desirable that a community-based clinic be located generally within 30 minutes’ travel time from a veteran’s home. Business Plans Document Time Frames for Establishing New Community-Based Clinics

In our prior work, we concluded that networks were not planning new community-based clinics on a strategic basis and that an overall plan was not available to permit an assessment of network activities from a systemwide perspective. This goal, however, focuses on outputs—the number of clinics—rather than on the desired outcome of increasing the percentage of current users having reasonable geographic access to primary care. As a result, networks’ planning efforts focus on the number of community-based clinics to be established and do not address the extent to which new clinics will achieve equity of access for current users among networks or enroll new users in accordance with statutory priorities. Consequently, we remain concerned about how effectively these clinics are used to equalize veterans’ access to VHA primary care within and among networks. This is attributable primarily to the additional clinics that the networks plan to establish over the next 5 years. Our assessment of network business plans and proposals for the 133 clinics suggests that the result of network planning will be to improve access for thousands of lower priority new users in 1998 and 1999, while thousands of higher priority current users may wait until 2000 or beyond for improved access. Network Oversight of Clinic Operations Varies Widely

Networks included a description of their evaluation plans in their clinic proposals, as VHA guidelines require. In addition, few have been implemented, primarily because most clinics have operated less than 6 months. VHA’s August 1996 guidelines added a requirement that networks develop evaluation plans for each new clinic proposed. Five networks reported that they did not have a common set of criteria. Networks Have Performed Few Clinic Evaluations

Our assessment of the evaluations performed to date shows that clinic evaluations do not adequately address VHA’s intent that clinics be evaluated to show how they are achieving the network’s purposes, goals, and objectives. Additional VHA guidance and other VHA assistance in developing networks’ 1999 business plans could result in a more consistent and thorough strategy for using clinics to equalize veterans’ geographic access to VHA primary care systemwide. Require networks to include in their business plans the percentage of (1) current users, by priority status, who have reasonable access; (2) the remaining current users (without reasonable access), by priority status, who are targeted to receive improved access through the establishment of community clinics by 2002; and (3) current users, by priority status, who will not have reasonable access by 2002.
Why GAO Did This Study

Pursuant to a congressional request, GAO provided information on the Veterans Health Administration's (VHA) use of community-based clinics to improve veterans' access to primary care, focusing on: (1) VHA's planning process for new community-based clinics; (2) networks' implementation of VHA's planning guidelines; and (3) VHA and network oversight of clinic operations.

What GAO Found

GAO noted that: (1) VHA has strengthened the process that networks are to use when establishing new community-based clinics, thereby addressing several of GAO's recommendations; (2) VHA provided more detailed guidance, including a 30-minute travel standard and an expectation that clinics be established primarily to benefit current users rather than attract new users; (3) VHA developed a more structured planning process, including the development of network business plans covering a 5-year period, and established a task force in accordance with VHA's guidelines; (4) VHA's long-range goal is to increase the number of community-based clinics; (5) to that end, VHA has approved 198 clinics, and network business plans show that 402 additional clinics are to be established between 1998 and 2002; (6) the plans, however, do not address the percentage of current users who have reasonable access, or what percentage of those without reasonable access are targeted to receive enhanced access through the establishment of new clinics; (7) as a result, VHA's network business plans cannot be used to determine on a systemwide basis how well networks are using clinics to equalize veterans' access to primary care; (8) based on the limited information that networks can provide, it appears that the geographic accessibility of VHA primary care currently varies widely among networks and that while networks' efforts should reduce this variation, thousands of the VHA's 3.4 million current users will likely continue to have inequitable access for many years; (9) moreover, it appears that networks are planning to improve access for thousands of lower priority new users over the next two years, while thousands of higher priority current users are waiting considerably longer periods of time for reasonable access; (10) networks, which have primary responsibility for monitoring community-based clinic performance, have developed evaluation plans for proposed clinics, as VHA requires; (11) to date, few clinics have operated for more than 12 months; (12) as a result, most evaluation plans have not been implemented; and (13) network evaluation plans, however, vary widely, with few containing a common set of criteria or indicators that appear necessary to effectively assess clinic evaluations to monitor performance within or among networks.