Nursing Homes: Better Oversight Needed to Protect Residents from Abuse

Nationwide, about 1.4 million elderly or disabled individuals receive care in more than 15,500 nursing homes. CMS, an agency within the Department of Health and Human Services (HHS), defines standards nursing homes must meet to participate in the Medicare and Medicaid programs.

Nursing home residents often have physical or cognitive limitations that can leave them particularly vulnerable to abuse. Abuse of nursing home residents can occur in many forms—including physical, mental, verbal, and sexual—and can be committed by staff, residents, or others in the nursing home. Any incident of abuse is a serious occurrence and can result in potentially devastating consequences for residents, including lasting mental anguish, serious injury, or death.

This statement summarizes GAO's June 2019 report, GAO-19-433 . Specifically, it describes: (1) the trends and types of abuse in recent years, and (2) CMS's oversight intended to ensure residents are free from abuse. It also includes a brief summary of findings and recommendations from this June 2019 report and prior GAO reports that examined the health and welfare of the elderly in multiple settings, and the status, as of November 2019, of HHS's efforts to implement the recommendations GAO made.

The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring nursing homes meet federal quality standards, including that residents are free from abuse. CMS enters into agreements with state survey agencies to conduct surveys of the state's homes and to investigate complaints and incidents.

GAO's June 2019 report found that, while abuse deficiencies cited in nursing homes were relatively rare from 2013 through 2017, they more than doubled during that time, increasing from 430 in 2013 to 875 in 2017, with the largest increase in severe cases. In light of the increased number and severity of abuse deficiencies, it is imperative that CMS have strong nursing home oversight in place to protect residents from abuse. However, GAO found oversight gaps that may limit the agency's ability to do so. Specifically, GAO found:

(1) Information on abuse and perpetrator types is not readily available. CMS's data do not allow for the type of abuse or perpetrator to be readily identified by the agency. Specifically, CMS does not require the state survey agencies to record abuse and perpetrator type and, when this information is recorded, it cannot be easily analyzed by CMS. GAO made a recommendation that CMS require state survey agencies to submit data on abuse and perpetrator type and HHS concurred. As of November 2019, HHS had not implemented the recommendation.

(2) Facility-reported incidents lack key information. Despite federal law requiring nursing homes to self-report allegations of abuse and covered individuals to report reasonable suspicions of crimes against residents, CMS has not provided guidance to nursing homes on what information they should include in facility-reported incidents, contributing to a lack of information for state survey agencies and delays in their investigations. GAO made a recommendation that CMS develop guidance on what abuse information nursing homes should self-report and HHS concurred. As of November 2019, HHS had not implemented the recommendation.

(3) Gaps exist in the CMS process for state survey agency referrals to law enforcement. GAO found gaps in CMS's process for referring incidents of abuse to law enforcement. These gaps may limit CMS's ability to ensure that nursing homes meet federal requirements for residents to be free from abuse. Specifically, GAO identified issues related to (1) referring abuse to law enforcement in a timely manner, (2) tracking abuse referrals, (3) defining what it means to substantiate an allegation of abuse—that is, the determination by the state survey agency that evidence supports the abuse allegation, and (4) sharing information with law enforcement. GAO made four recommendations to address these gaps and HHS concurred. As of November 2019, HHS had not implemented these recommendations.

I am pleased to submit this statement on GAO’s work related to nursing  home resident safety. Specifically, this statement discusses GAO’s recent  report on the abuse of nursing home residents and the Centers for  Medicare & Medicaid Services’ (CMS) oversight. Nationwide, about 1.4  million elderly or disabled individuals receive care in more than 15,500  nursing homes. These nursing home residents often have physical or  cognitive limitations that can leave them particularly vulnerable to abuse.  Abuse of nursing home residents can occur in many forms—including  physical, mental, verbal, and sexual—and can be committed by staff,  residents, or others in the nursing home. Any incident of abuse is a  serious occurrence and can result in potentially devastating  consequences for residents, including lasting mental anguish, serious  injury, or death. News stories in recent years have noted disturbing  examples of nursing home residents who have been sexually assaulted  and physically abused. However, little is known about the full scope of  nursing home abuse, as incidents of abuse may be underreported.

Federal law mandates that nursing homes receiving Medicare or  Medicaid payments ensure that residents are free from abuse. To help  ensure this, CMS, an agency within the Department of Health and Human  Services (HHS), defines the quality standards that nursing homes must  meet in order to participate in the Medicare and Medicaid programs. To  monitor compliance with these standards, CMS enters into agreements  with agencies in each state government—known as state survey  agencies—and oversees the work the state survey agencies do. This  work includes conducting required, comprehensive, on-site standard  surveys of every nursing home approximately once each year and  investigating both complaints from the public and incidents self-reported  by the nursing home (referred to as facility-reported incidents) regarding  resident care or safety. If a surveyor determines that a nursing home  violated a federal standard during a survey or investigation, then the  home receives a deficiency citation, also known as a deficiency. In  addition to state survey agencies, there are other state and local agencies  that may be involved in investigating abuse in nursing homes, including  Adult Protective Services, local law enforcement, and Medicaid Fraud  Control Units (MFCU) in each state, which are tasked with investigating  and prosecuting a variety of health care-related crimes.

We have previously reported on problems in nursing home quality,  including challenges protecting residents from abuse and weaknesses in  CMS’s oversight. For example, in multiple reports dating back to 1998, we  have identified weaknesses in federal and state activities designed to  correct quality problems in nursing homes. Specifically, in a 2002 report,  we found that CMS needed to do more to protect nursing home residents  from abuse, and we made five recommendations to help CMS facilitate  the reporting, investigation, and prevention of abuse in nursing homes.  More recently, in April 2019 we reported that CMS had failed to address  gaps in federal oversight of nursing home abuse investigations in  Oregon—an issue that we uncovered during the course of our broader  work on nursing home resident abuse. Further, reports by the HHS  Office of the Inspector General (OIG) have also reviewed incidents of  resident abuse and raised concerns about CMS’s procedures.

This statement highlights key findings and recommendations from our  June 2019 report, which examined:  1.  the trends and types of abuse occurring in nursing homes in recent  2.  the risk factors for abuse and challenges facing stakeholder agencies  involved in investigating abuse in nursing homes, and  3.  CMS’s oversight intended to ensure that nursing home residents are  free from abuse.

In this statement, we include information on the status, as of November  2019, of HHS’s efforts to implement the recommendations in our June  2019 report. In appendix I, we also include a summary of findings and  recommendations from prior GAO reports that examined the health and  welfare of the elderly in multiple settings, such as abuse in nursing  homes, assisted living facilities, and in the community. A list of related  GAO reports from our larger body of work examining federal oversight of  the quality of care and the safety of older adults receiving care in these  settings is included at the end of this statement.

To conduct the work for our June 2019 report, we reviewed federal laws  and CMS guidance, analyzed CMS data, and interviewed stakeholders  from selected states. First, we reviewed federal laws and CMS guidance  to determine the federal standards and associated deficiency codes  related to resident abuse. Second, we analyzed data provided by CMS to  identify the number and severity of abuse deficiencies cited by surveyors  in all 50 states and Washington, D.C., between 2013 and 2017. Because  abuse and perpetrator type are not readily identifiable in CMS’s data, we  identified this information by reviewing a randomly selected  representative sample of 400 CMS abuse deficiency narratives written by  state surveyors from 2016 through 2017 that describe the substantiated  abuse. Finally, we interviewed CMS officials and officials from a non- generalizable sample of survey agencies from five states—Delaware,  Georgia, Ohio, Oregon, and Virginia. We also interviewed other  stakeholders in these states, including officials from each state’s long- term care ombudsmen, law enforcement, MFCUs, and, when appropriate,  Adult Protective Services. We also visited nursing homes and spoke to  administrators and clinical staff in each of these states. We assessed  CMS’s oversight activities in the context of the federal standards for  internal control. (Further details on our scope and methodology are  included in our report). To determine the status of the recommendations  we made in our June 2019 report, we obtained information from CMS  officials in November 2019.

We conducted the work on which this statement is based 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.

Improved CMS Oversight Is Needed to Better Protect Residents from Abuse

In our June 2019 report, we found that, while abuse deficiencies cited in  nursing homes were relatively rare from 2013 through 2017, they became  more frequent during that time, with the largest increase in severe cases.  Specifically, abuse deficiencies comprised less than 1 percent of the total  deficiencies in each of the years we examined, which is likely  conservative. Abuse in nursing homes is often underreported by  residents, family, staff, and the state survey agency, according to CMS  officials and stakeholders we interviewed. However, abuse deficiencies  more than doubled—from 430 in 2013 to 875 in 2017—over the 5-year  period. (See appendix II.) In addition, abuse deficiencies cited in 2017  were more likely to be categorized at the highest levels of severity— deficiencies causing actual harm to residents or putting residents in  immediate jeopardy—than they were in 2013. In light of the increased  number and severity of abuse deficiencies, it is imperative that CMS have  strong nursing home oversight in place to protect residents from abuse;  however, we found oversight gaps that may limit the agency’s ability to do  so. Specifically, we found that CMS: (1) cannot readily access data on the  type of abuse or type of perpetrator, (2) has not provided guidance on  what information nursing homes should include in facility-reported  incidents, and (3) has numerous gaps in its referral process that can  result in delayed and missed referrals to law enforcement.

Information on Abuse and Perpetrator Types Is Not Readily Available

In our June 2019 report, we found that CMS’s data do not allow for the  type of abuse or perpetrator to be readily identified by the agency.  Specifically, CMS does not require the state survey agencies to record  abuse and perpetrator type and, when this information is recorded, it  cannot be easily analyzed by CMS. Therefore, we reviewed a  representative sample of 400 CMS narrative descriptions—written by  state surveyors—associated with abuse deficiencies cited in 2016 and  2017 to identify the most common types of abuse and perpetrators. From  this review, we found that physical abuse (46 percent) and mental/verbal  abuse (44 percent) occurred most often in nursing homes, followed by  sexual abuse (18 percent). Furthermore, staff, which includes those  working in any part of the nursing home, were more often the perpetrators  (58 percent) of abuse in deficiency narratives, followed by resident  perpetrators (30 percent) and other types of perpetrators (2 percent).  (See appendix III for examples from our abuse deficiency narrative  review.)

CMS officials told us they have not conducted a systematic review to  gather information on abuse and perpetrator type. Further, based on  professional experience, literature, and ad hoc analyses of deficiency  narrative descriptions, CMS officials told us they believe the majority of  abuse is committed by nursing home residents and that physical and  sexual abuse were the most common types. This understanding does  not align with our findings on the most common types of abuse and  perpetrators represented in CMS’s data on deficiencies cited as abuse.  Without the systematic collection and monitoring of specific abuse and  perpetrator data, CMS lacks key information and, therefore, cannot take  actions—such as tailoring prevention and investigation activities—to  address the most prevalent types of abuse or perpetrators. To address  this, we recommended that CMS require state survey agencies to report  abuse and perpetrator type in CMS’s databases for deficiency, complaint,  and facility-reported incident data and that CMS systematically assess  trends in these data. HHS concurred with our recommendation and stated  that it plans to implement changes in response. As of November 2019,  HHS had not implemented the recommendation.

Facility-Reported Incidents Lack Key Information

Despite federal law requiring nursing homes to self-report allegations of  abuse and covered individuals to report reasonable suspicions of crimes  against residents, in June 2019 we reported that CMS had not provided  guidance to nursing homes on what information they should include in  facility-reported incidents, contributing to a lack of information for state  survey agencies and delays in their investigations. Specifically, officials  from each of the five state survey agencies told us that the documentation  they receive from nursing homes for facility-reported incidents can lack  key information that affects their ability to triage incidents and determine  whether an investigation should occur and, if so, how soon. For example,  officials from two state survey agencies we interviewed said they  sometimes have to conduct significant follow-up with the nursing homes  to obtain the information they need to prioritize the incident for  investigation—follow-up that delays and potentially negatively affects  investigations. Incomplete incident reports from nursing homes are  particularly problematic given that nearly half of abuse deficiencies cited  between 2013 and 2017 were identified through facility-reported  incidents, which is dramatically different than the approximately 5 percent  of all types of deficiencies that were identified in this manner. Therefore, facility-reported incidents play a unique and significant role in identifying  abuse deficiencies in nursing homes, making it critical that incident  reports provided by nursing homes include the information necessary for  state survey agencies to prioritize and investigate. To address this issue,  we recommended that CMS develop and disseminate guidance— including a standardized form—to all state survey agencies on the  information nursing homes and covered individuals should include on  facility-reported incidents. HHS concurred with our recommendation and  stated that it plans to implement changes in response. As of November  2019, HHS had not implemented the recommendation.

Gaps Exist in CMS Process for State Survey Agency Referrals to Law Enforcement and MFCUs

In June 2019, we identified gaps in CMS’s process for referring incidents  of abuse to law enforcement and, if appropriate, to MFCUs. These gaps  may limit CMS’s ability to ensure that nursing homes meet federal  requirements for residents to be free from abuse. Specifically, we  identified issues related to (1) referring abuse to law enforcement in a  timely manner, (2) tracking abuse referrals, (3) defining what it means to  substantiate an allegation of abuse—that is, the determination by the  state survey agency that evidence supports the abuse allegation, and (4)  sharing information with law enforcement. We made recommendations  that CMS address each of these four gaps in the referral process, and  HHS concurred with each recommendation and stated that it plans to  implement changes in response. As of November 2019, HHS had not  implemented these recommendations.

One of the gaps in CMS’s process is related to referring abuse to law  enforcement in a timely manner. For example, law enforcement  investigations can be significantly delayed because CMS requires a state  survey agency to make referrals to law enforcement only after abuse is  substantiated—a process that can often take weeks or months. Officials  from one law enforcement agency and two MFCUs we interviewed told us  the delay in receiving referrals limits their ability to collect evidence and  prosecute cases—for example, bedding associated with potential sexual  abuse may have been washed, and a victim’s wounds may have  healed. As such, we recommended that CMS require state survey  agencies to immediately refer to law enforcement any reasonable  suspicion of a crime against a resident. HHS concurred with our  recommendation and stated that it plans to implement changes in  response. As of November 2019, HHS had not implemented this  recommendation.

In conclusion, while nursing home abuse is relatively rare, our June 2019  report shows that abuse deficiencies cited in nursing homes are  becoming more frequent, with the largest increase in severe cases. It is  imperative that CMS have more complete and readily available  information on abuse to improve its oversight of nursing homes. It is also  essential that CMS require state survey agencies to immediately report  incidents to law enforcement if they have a reasonable suspicion that a  crime against a resident has occurred in order to ensure a prompt  investigation of these incidents.

Chairman Neal, Ranking Member Brady, and Members of the Committee,  this concludes GAO’s statement for the record.

For further information about this statement, please contact John E.  Dicken at (202) 512-7114 or dickenj@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this statement. In addition to the contact named above,  key contributors to this statement were Karin Wallestad (Assistant  Director), Sarah-Lynn McGrath (Analyst-in-Charge) and Summar C.  Corley. Also contributing to the underlying report for this statement were  Luke Baron, Julianne Flowers, Laurie Pachter, Vikki Porter, Kathryn  Richter, and Jennifer Whitworth.

Appendix I: Summary of GAO Reports on the Health and Welfare of the Elderly

We have issued a number of reports reviewing the health and welfare of  the elderly in multiple settings. For example, since January 2015, we  have issued reports on the incidence of abuse in nursing homes and what  is known about the incidence of abuse in assisted living facilities. Reports  often included key recommendations. (See table 1.)

Appendix II: Severity of Abuse Deficiencies  Cited in Nursing Homes, 2013 through 2017 CMS restructured its deficiency code system beginning on November 28, 2017. Due to these coding  changes, we did not analyze CMS data cited by surveyors after the implementation of that change.

Percentages may not add to 100 due to rounding.

Appendix III: Examples from a Representative Sample of Nursing Home Abuse Deficiency Narratives, 2016-2017

Elder Abuse: Federal Requirements for Oversight in Nursing Homes and  Assisted Living Facilities Differ. GAO-19-599. Washington, D.C.: August  19, 2019.

Nursing Homes: Improved Oversight Needed to Better Protect Residents  from Abuse. GAO-19-433. Washington, D.C.: June 13, 2019.

Elder Justice: Goals and Outcome Measures Would Provide DOJ with  Clear Direction and a Means to Assess Its Efforts. GAO-19-365.  Washington, D.C.: June 7, 2019.

Management Report: CMS Needs to Address Gaps in Federal Oversight  of Nursing Home Abuse Investigations That Persisted in Oregon for at  Least 15 Years. GAO-19-313R. Washington, D.C.: April 15, 2019.

Medicaid Assisted Living Services: Improved Federal Oversight of  Beneficiary Health and Welfare is Needed. GAO-18-179. Washington,  D.C.: January 5, 2018.

Medicaid Managed Care: CMS Should Improve Oversight of Access and  Quality in States’ Long-Term Services and Supports Programs. GAO-17- 632. Washington, D.C.: August 14, 2017.

Medicaid Personal Care Services: CMS Could Do More to Harmonize  Requirements across Programs. GAO-17-28. Washington, D.C.:  November 23, 2016.

Nursing Homes: Consumers Could Benefit from Improvements to the  Nursing Home Compare Website and Five-Star Quality Rating System.  GAO-17-61. Washington, D.C.: November 18, 2016.

Elder Abuse: The Extent of Abuse by Guardians is Unknown, but Some  Measures Exist to Help Protect Older Adults. GAO-17-33. Washington,  D.C.: November 16, 2016.

Skilled Nursing Facilities: CMS Should Improve Accessibility and  Reliability of Expenditure Data. GAO-16-700. Washington, D.C.:  September 7, 2016.

Nursing Home Quality: CMS Should Continue to Improve Data and  Oversight. GAO-16-33. Washington, D.C.: October 30, 2015.

Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older  Adults in Nursing Homes, but Should Expand Efforts to Other Settings.  GAO-15-211. Washington, D.C.: January 30, 2015.

This is a work of the U.S. government and is not subject to copyright protection in the  United States. The published product may be reproduced and distributed in its entirety  without further permission from GAO. However, because this work may contain  copyrighted images or other material, permission from the copyright holder may be  necessary if you wish to reproduce this material separately.

To protect vulnerable nursing home residents from abuse, the Centers for Medicare & Medicaid Services (CMS) contracts with state agencies—known as survey agencies—that can cite nursing homes for incidents of abuse.

Our June 2019 report found that, while abuse in nursing homes is often underreported, abuse citations more than doubled from 2013-2017. We also found gaps in CMS’s oversight that made it harder to protect residents and we made six recommendations to address this.

This statement for the record updates the status of these recommendations and others from prior GAO reports that examined the health and welfare of the elderly.


VA Disability Compensation: Actions Needed to Enhance Information about Veterans' Health Outcomes

VA receives billions of dollars per year to provide health care and disability compensation to promote the wellness of veterans with service-connected conditions. VA studies veterans' health through research and assesses changes in service-connected conditions through its reevaluation process.

GAO was asked to review VA's efforts to study and gauge the health outcomes of veterans with service-connected conditions. This report examines the extent to which (1) veterans used VA health care services to treat service-connected conditions, and what is known about their health outcomes; (2) VA uses information on reevaluations to help manage the program; and (3) VA's procedures position it to determine when to conduct a reevaluation.

GAO reviewed fiscal year 2018 VA health care data; selected studies; VA data on completed reevaluations from fiscal years 2013-2018; and relevant federal laws, regulations, and program guidance. GAO also interviewed staff at four VA regional offices (selected for variation in claims workload and location) and VA officials at the agency's central office.

In fiscal year 2018, about 54 percent of veterans receiving Department of Veterans Affairs (VA) disability compensation had at least one VA outpatient visit to treat an injury or illness that VA deemed was incurred or aggravated during military service (i.e., a service-connected condition). However, the health outcomes of veterans with service-connected conditions, such as changes in the severity of symptoms or the incidence of mortality, are not well understood. Information about health outcomes is central to ensuring veterans' wellness and assessing improvement in their disability status. According to VA researchers GAO spoke with and academic studies GAO reviewed, various challenges have limited research on this population. For example, data reside in different VA systems and use different identifiers for medical conditions, hindering use of the data. While VA has begun to consider ways to analyze health outcomes, it has not yet established a plan for this effort, including the scope, specific activities, and timeframes for addressing the identified research challenges.

VA does not glean information from the results of reevaluations to help manage its disability compensation program. Disability reevaluations help VA gauge whether veterans' service-connected conditions have changed, and whether disability compensation should be modified to reflect those changes (see figure).

However, VA does not fully use key management information, such as:

trends in how frequently certain conditions are reevaluated, including those required by VA regulations to be reevaluated; and

outcomes of reevaluation decisions for individual conditions (i.e., whether conditions worsened or improved).

Both trend and outcome information could help VA better target its resources toward reevaluating conditions more likely to change.

VA recently updated its procedures manual to specify which staff may determine whether a veteran's condition should be reevaluated, but has not clearly defined skill sets and training needed to consistently implement these procedures. Specifically, the updated procedures do not indicate the knowledge, skills, and abilities staff need to determine when to conduct reevaluations. Further, VA has not ensured that training aligns with these needed skillsets. Without improving procedures and training, VA is at risk of conducting unnecessary reevaluations and burdening veterans.

GAO is making five recommendations, including that VA develop a plan to address challenges to studying health outcomes, use information on reevaluations to improve program management, and improve procedures and training for reevaluations. VA agreed with two recommendations and agreed in principle with the other three, but its proposed actions do not fully address GAO's concerns.

A sacrifice of military service can include sustaining a disability, and the  Department of Veterans Affairs’ (VA) mission is to care for those who  “shall have borne the battle.” To promote the wellness of veterans who  incurred or aggravated disabling conditions during military service  (service-connected conditions), VA receives appropriations of tens of  billions of dollars per year to provide health care, disability compensation,  and other forms of assistance.

Gauging whether VA care and benefits are associated with a change in  health outcomes for veterans with service-connected conditions is  important for better serving these veterans. Two ways of determining  changes in veterans’ health are (1) researching the health treatment for  service-connected conditions, and (2) assessing service-connected  conditions through VA’s disability reevaluation process.

Research, conducted by VA’s Veterans Health Administration (VHA),  involves studies on changes in veterans’ health among a group of  veterans, such as changes in the severity of their symptoms or the  incidence of mortality or disease complications.

The reevaluation process, administered by VA’s Veterans Benefits  Administration (VBA) and its 57 regional offices, involves VA  determining whether an individual veteran’s service-connected  condition has changed, due to treatment or other factors in the years  following an evaluation for disability compensation.

Against this backdrop, you asked us to review issues involving health  care for veterans receiving disability compensation and VA’s  management of the program. This report examines the extent to which (1)  veterans receiving VA disability compensation use VA health care  services to treat their service-connected conditions, and what is known  about their health outcomes; (2) VA uses information on reevaluations to  help manage the program; and (3) VA’s procedures position the agency  to determine when to conduct a reevaluation.

To address the first objective, we analyzed VA fiscal year 2018 data on  the number and type of inpatient and outpatient health care visits by  veterans for their service-connected conditions. We assessed the  reliability of these data by conducting electronic testing, reviewing data  system documentation, and interviewing staff knowledgeable about the  data. We determined these data were reliable for our purposes. We also  conducted a literature search for information on VA health care use for  service-connected conditions to offer additional insights into this data  analysis. To determine what is known about health outcomes for  veterans’ service-connected conditions, we conducted a literature review,  searching a number of social science and medical databases to identify  studies on health care utilization and health outcomes for service- connected conditions. We also consulted with VA health research officials  to identify relevant studies. We looked at studies that met the following  criteria: (1) original research published from 2008 to mid-2019, (2) study  populations based in the United States, and (3) discussion of outcomes  for health conditions for which veterans were awarded disability  compensation benefits. As a result, we identified two studies relevant to  health outcomes specifically for this population. We evaluated each  study’s methodology and results and found them reliable for our purposes  in providing insights into health outcomes. In addition, we interviewed  VHA officials, VHA health care researchers, and VBA officials about  ongoing research on health outcomes for service-connected conditions  and the benefits and challenges of conducting this research.

For the second and third objectives, we selected four VBA regional offices  for more in-depth review: Boston, MA; St. Louis, MO; Salt Lake City, UT;  and Seattle, WA, and made in-person visits to Boston and Seattle. For  each office we obtained documentation pertaining to their processes and  plans regarding reevaluations and interviewed people responsible for the  reevaluation process including claims processors, quality reviewers, and  managers. Although the information we obtained from interviews with  regional office officials provides views on the reevaluation process, this  information cannot be generalized to all regional officials and offices. The  four offices were selected to obtain variation on the volume of completed  reevaluations and diverse locations.

For the second objective, we reviewed relevant federal laws and  regulations as well as VA policies and procedures pertaining to  reevaluations. These include VA’s procedures and goals for measuring  claims processing accuracy and timeliness, and its management  practices for addressing performance issues with reevaluation decisions.  We assessed VA’s efforts against best practices for use of performance  information. We also assessed VA’s efforts against federal standards for  internal control related to monitoring. We analyzed VBA data on  completed reevaluations conducted from fiscal year 2013 through fiscal  year 2018. We assessed the reliability of these data by conducting  electronic testing, examining data system documentation and interviewing  staff knowledgeable about the data; we determined that these data were  reliable for our purposes.

For the third objective, we reviewed relevant federal laws and regulations  as well as VA policies and procedures pertaining to reevaluations,  including guidance and training. We compared these procedures to  federal standards for internal control related to designing appropriate  control activities to achieve program objectives. We also assessed VA’s  procedures against key practices for training and development.

We conducted this performance audit from July 2018 to December 2019  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.

VA pays monthly disability compensation to veterans with disabling  conditions caused or aggravated by their military service. The benefit is  based on an average reduction in earning capacity across a group of  individuals with similar physical or mental impairments. Disability  compensation is generally paid according to the severity of the service- connected condition and is awarded in 10 percent increments, based on  criteria in the VA Schedule for Rating Disabilities (VASRD or rating  schedule).

Veterans may claim more than one medical condition, and VBA assigns a  rating percentage for each condition determined to be connected to the  veteran’s service. For veterans with multiple service-connected  conditions, VA calculates a rating (combined disability rating) using a  table that applies a formula for combining multiple ratings into a single  rating. The rating affects the amount of monthly compensation received  by a veteran.

Unlike some private-sector disability programs, the employment status,  earnings, and ability to work generally are not factored into the disability  rating and subsequent base payment. Moreover, unlike typical workers’  compensation programs for permanent impairments, no limits are  generally placed on the length of time veterans can receive payments.

Obligations for disability compensation have increased by 45 percent in  the last 5 years, from about $54 billion in fiscal year 2013 to about $78  billion in fiscal year 2018. According to VA, this increase is due to several  factors, including more beneficiaries (for example, as veterans of more  recent conflicts leave military service and seek compensation), as well as  rising average disability ratings that lead to higher average payments. VA  reported that growth in the number of veterans with a service-connected  condition is concentrated among those rated 50 percent or higher.

VBA’s Compensation Service sets policy and oversees the process for  determining eligibility for disability compensation. VBA staff in the  regional offices process disability compensation claims. These claims  processors include Rating Veterans Service Representatives (RVSR or  rater), who decide on benefit entitlement and the rating percentage, and  Veterans Service Representatives (VSR), who gather evidence needed  for the raters to make their decisions and later authorize payment, if any.  Claims processors use the Veterans Benefits Management System  (VBMS)—an electronic, paperless system—to maintain, review, and  make rating decisions for veterans’ claims.

VBA’s reevaluation process determines whether veterans’ service- connected conditions may have changed, due to treatment or other  factors, in the years following an initial evaluation for disability  compensation. This process helps ensure that veterans’ service- connected conditions are being rated and compensated correctly.

A first step in the process is deciding whether a condition may need to be  reevaluated at a future date. As part of an evaluation for disability  compensation, claims processors review medical evidence and consider  whether to schedule a future review date (see fig.1). When the scheduled  review date arrives, VBA revisits the case to determine whether a  reevaluation of the disabling condition is still appropriate. This pre-exam  review involves reviewing the veteran’s records to determine if the  veteran is still experiencing similar symptoms. After this review, VBA may  conduct, postpone, or cancel a reevaluation. If the reevaluation is  conducted, a medical exam may be ordered, after which the rater will rate  the condition based on exam results and other medical evidence.

VBA regulations specify certain conditions that require reevaluation. In  other instances, VA has discretion in whether to conduct reevaluations,  determined upon review of a veteran’s medical record. For example, the  medical record may suggest that a veteran with limited range of motion  will be continuing physical rehabilitation and is expected to improve.  Whether the reevaluation is required or discretionary, VBA’s regulations  outline several exclusions that place limits on when VBA conducts  reevaluations, such as if the veteran’s combined disability rating would  not change as a result of a reduced evaluation for one or more conditions.

Veterans may generally obtain health care through (1) VA medical  facilities, (2) non-VA health care providers in the community for which VA  pays (called community care), or (3) providers paid through veterans’ own  health insurance.

For VA medical facilities, VHA determines eligibility and priority for VA  health care, enrolls veterans, and oversees 172 VA medical centers and  over 1,000 outpatient facilities. In response to the Veterans’ Health Care  Eligibility Reform Act of 1996, VHA developed a priority system to  balance demand for health care with available resources. The system has  eight priority groups, and first priority is generally given to veterans with  service-connected conditions rated 50 percent or more and to veterans  deemed unemployable because of service-connected conditions. Priority  groups 2 and 3 include veterans with service-connected conditions rated  30 or 40 percent, or 10 or 20 percent, respectively, according to VHA.

Veterans may be eligible for community care if, for example, VA does not  offer the care or service the veteran requires, or when a VA medical  facility is unable to provide the care or services consistent with the  agency’s access standards. Before receiving health care through VA  community care programs, veterans must generally obtain authorization  from VA.

The total number of veterans enrolled in VA’s health care system rose  from 7.9 million to over 9 million from fiscal years 2006 through 2017.

During that period, VHA’s budget more than doubled, from $37.8 billion to  $92.3 billion, as health care costs were rising and its community care  programs were expanding. In fiscal year 2017, VA obligated $13.6 billion  of its budget for community care, and in fiscal year 2018, this increased to  $14.9 billion.

For health care services delivered outside of VHA medical facilities that  are not funded by VA, veterans may use private health insurance. A  2018 VA survey of veterans enrolled in VA’s health care system found  that about 28 percent reported being covered by private insurance.

VBA Regional Office Performance Information for Disability Compensation Claims Processing

VBA tracks its performance in providing timely and accurate disability  compensation decisions to veterans. VBA considers a decision to be  timely if a veteran’s claim is processed within 125 days. As part of its  quality assurance efforts, VBA conducts national and individual reviews of  the accuracy of claims decisions, and periodic consistency studies to  assess claims processors’ knowledge of regulations and guidance on  specific claims processing issues, such as when to conduct  reevaluations.

At the VBA central office level, procedures call for VA to assess the  accuracy of a random sample of completed claims from each regional  office using its Systematic Technical Accuracy Review (STAR)  method. STAR reviewers use a standardized checklist to review all  actions taken in processing a claim and record any errors they find.  VA reports national and regional office performance data for claim- based accuracy (based on the entirety of the claim) and issue-based  accuracy (based on each of the individual medical conditions rated).

In fiscal year 2018, VBA reported claim-based rating accuracy of  about 90 percent and issue-based accuracy of about 95 percent.

At the VBA regional office level, quality review teams conduct  Individual Quality Reviews of individual claims processors’ work. For  example, VA’s procedures call for reviews to be performed on five  claims for every rater per month. The reviews are used to help assess  individual claims processors’ performance.

In addition to accuracy reviews, VBA’s national quality assurance efforts  include periodic consistency studies on specific claims processing issues.  These studies are intended to assess how consistently claims processors  are making decisions across all regional offices by testing select claims  processors on their knowledge of VBA’s regulations and procedures.

Differences between Improvements in Service- Connected Conditions and Health Outcomes

Improvements in a veteran’s service-connected conditions and  improvements in a veteran’s health outcomes have important differences.  Federal law requires disability compensation to be based upon an  average reduction in earning capacity across a group of individuals with a  similar physical or mental impairment. In addition, for certain service- connected conditions such as amputations, VA evaluates the condition  based on loss or loss of function of a body part or system, without  considering assistive devices or prosthetics. As such, some service- connected conditions, such as hearing loss, are generally not expected to  improve for purposes of disability compensation. In contrast, according  to VHA research, a veteran’s use of a hearing aid is an example of a  successful health outcome because this assistive technology can treat  the symptoms of hearing loss and increase the functioning of a person.

Many Veterans Use VA Health Care for Service-Connected Conditions, but Outcomes of This Care Are Not Well Understood

More Than Half of Veterans Receiving Disability Compensation Use VA Health Care for Service-Connected Conditions

For health care delivered at VA medical facilities, our analysis of fiscal  year 2018 VA data shows that more than half of veterans receiving  disability compensation used VA health care for a service-connected  condition. Specifically, we determined that about 54 percent of veterans,  or about 2.6 million, who received disability compensation had at least  one VA outpatient visit related to a service-connected condition.  Veterans with higher combined disability ratings had more outpatient  visits related to their service-connected conditions, on average.   (See fig. 2.) Veterans using VA health care for service-connected  conditions had an average of four such conditions, and the median age  was 63.

For veterans with the most prevalent service-connected conditions, in  fiscal year 2018 the average number of visits ranged from about 6 to 11  (see table 1). The highest average number of visits was for veterans with  service-connected post traumatic stress disorder (PTSD) and diabetes.  For the same year, veterans receiving disability compensation had an  average of nearly eight outpatient health care visits for service-connected  conditions.

In fiscal year 2018, about 13 percent of VA inpatient hospital stays for  veterans receiving disability compensation were to treat a service- connected condition; about 87 percent of the stays for this population  were to treat non-service-connected conditions.

Nearly 2.1 million, or about 44 percent of veterans receiving disability  compensation, had no VA outpatient visits or inpatient stays for their  service-connected conditions. These veterans may have received  treatment paid for through private insurance, from community care, or  received no treatment for their service-connected conditions in fiscal year  2018. Veterans who did not use VA health care had an average of about  four service-connected conditions, and the median age was 57.

For community care (VA-funded health care delivered by non-VA  providers), we could not determine the extent to which veterans receiving  VA disability compensation used these health providers for their service- connected conditions because this area is not a focus of analysis for the  program, according to VHA Office of Community Care officials. These  officials told us that, other than for emergency care claims, information on  service-connected conditions is not used to process authorizations and  payments for the program because program eligibility is based on other  factors, such as the availability of needed services.

Veterans also receive health care outside of VHA facilities that is not  funded by VA, such as through their private health insurance, and the  number and types of these services for service-connected conditions are  largely unknown. According to a statutorily mandated study of the use of  VA’s health care system, these data are limited. The authors of this  study recommended that VA consider expanding data collection efforts.  VA has since worked with the Department of Health and Human Services’  Agency for Healthcare Research and Quality to expand its data collection  regarding veterans, including veterans receiving disability compensation,  specifically regarding veterans’ use of non-VA care and coordinating such  care with VA providers. Data from this effort will be available beginning in  fiscal year 2020, according to Agency for Healthcare Research and  Quality researchers conducting the study.

Health Outcomes of Veterans Receiving VA Disability Compensation Are Not Well Understood

Health outcomes of veterans with service-connected conditions who  receive VA health care services are not well understood, as they have not  been specifically studied outside of veterans receiving disability  compensation for PTSD. Based on a review of peer-reviewed literature  and interviews with VA health research officials, we identified two studies  on the health outcomes of veterans, both of which specifically focused on  health outcomes for veterans receiving disability compensation for PTSD.

One study published in 2011 found that receiving disability  compensation benefits for PTSD was associated with clinically  meaningful reductions in PTSD symptoms and reductions in poverty  and homelessness.

Another study published in 2017 found that 10 percent of men and 20  percent of women who applied for disability compensation for PTSD  had a persistent serious mental illness, and over time, consistently  reported more severe PTSD symptoms and poorer functioning in  comparison to other study participants without severe mental illness.  The study authors noted that serious mental illness was more  prevalent in this population than in the VA health care system overall.  They concluded that more information is needed about the  characteristics of those receiving disability compensation to better  understand their challenges and long-term outcomes.

VA’s Health Services Research and Development office sponsors  research on health conditions common in the veteran population, such as  traumatic brain injury and Gulf War Illness, among others. According to  an official from this office, data used for these studies generally do not  include veterans’ receipt of disability compensation or their specific  service-connected conditions.

VA Data on Service- Connected Conditions and Health Care Are Not Easily Used to Study Health Outcomes of this Population

Several health care researchers within VA and a VA official we spoke with  cited various reasons for limited research on health outcomes for  veterans with service-connected conditions. According to these officials, a  key challenge is that VBA and VHA data do not use the same identifiers  for medical conditions that are needed to link the two information  sources. VA health care researchers acknowledged benefits to including  veterans’ VBA disability codes in their studies to analyze health  information for veterans with service-connected conditions. A 2007 report  on the options for improving the disability program also noted that the use  of common diagnostic categories would allow VA program managers and  researchers to compare populations and trends that would help in  program planning and in epidemiological and health services research.  However, VBA’s diagnostic codes are unique and do not allow  comparisons of trends in disabilities in populations served by VHA or the  Department of Defense.

According to a VA health care researcher and a VHA official, also  contributing to these challenges are the lack of data use agreements,  which could better facilitate linking VBA and VHA administrative data for  VA to further study health outcomes for this population. For example,  according to a VA researcher, linking these data sources could allow  researchers to investigate causal relationships between disability  compensation and veterans’ health outcomes. We previously reported  that such agreements can specify which data can be accessed and for  what purpose, the duration of access, and requirements for safeguarding  the data and ensuring confidentiality. VBA officials said that while they  routinely share data with VHA for operational purposes, obtaining access  to VBA data for research purposes has special requirements and is more  cumbersome. Agency health care data are stored in VHA’s Corporate  Data Warehouse, while benefits data are stored in VBA’s data  warehouse. Both VHA and VBA officials noted that their data contain  sensitive information and that access is carefully monitored.

VA’s fiscal year 2018-2024 Strategic Plan includes goals and objectives  for data-driven decision making, which include having comprehensive  data to identify and meet veterans’ needs, as well as to understand the  outcomes VA provides veterans and focus VA’s improvement efforts. In  addition, we have previously reported that agencies can enhance and  sustain their collaborative efforts by defining common outcomes,  leveraging resources, and establishing compatible policies, among  others. These practices include articulating agreements in formal  documents, which can strengthen the commitment to working  collaboratively, as well as establishing compatible policies and other  means (including compatible standards and data systems) to operate  across agency boundaries.

VA has begun to consider ways to analyze health care services received  by veterans with service-connected conditions. VA’s Office of Enterprise  Integration (OEI) is tasked with providing analysis to inform VA decision- making, as well as to align planning and implementation across VA  programs and initiatives. According to an OEI official, it plans to convene  subject matter experts from VBA and VHA to determine options and pilot  strategies to link available data, but has not yet determined the scope,  specific activities, or timeframes for this effort. Until VA develops and  implements a plan to address challenges that have hindered analysis  thus far and enhance collaboration between VBA and VHA with regard to  such analysis, VA will not be positioned to understand the characteristics,  needs, and health outcomes of veterans with service-connected  conditions, which available research suggests may be different from other  veterans.

VBA Does Not Fully Use Information on Reevaluations to Manage the Disability Compensation Program

VBA Does Not Fully Use Trend and Outcome Information on Completed Reevaluations to Aid Future Decision Making About Which Conditions to Reevaluate

VBA uses some information on conditions identified as potentially  needing reevaluations; however, it is not analyzing and using trend and  outcome information from completed reevaluations to inform which  service-connected conditions to reevaluate in the future. Reevaluations of  veterans’ service-connected conditions can serve as a proxy to gauge  change, including improvement, in health. VBA assesses changes in  veterans’ disabling conditions from reevaluations it conducts for various  reasons, including evidence of potential improvement or when required by  the rating schedule. A reevaluation showing a change in a given condition  may result in one of three possible outcomes: an increase, decrease, or  no change in the veteran’s associated disability rating.

VBA developed a report to help identify unnecessary reevaluations, which  included information on veterans’ conditions that are initially flagged by  raters for potentially needing reevaluations in the future. Developed in  2017, VBA’s report identified potential reevaluations deemed  unnecessary per VA’s regulations. For example, regulations state that  veterans older than 55 are generally exempt from reevaluation, according  to the VA Office of Inspector General (OIG). As part of this process,  potential reevaluations identified as unwarranted by VBA’s report would  be cancelled before their scheduled review dates arrived.

This report also includes information on specific conditions identified for  potential reevaluation, including the subset of conditions required by  regulation to be reevaluated. For example, according to the data  generated by the report in June 2019, PTSD was the most common  condition identified for potential reevaluation, and of the conditions  requiring reevaluation, prostate cancer was most common. However,  VBA officials explained that if the report were to find that any of the cases  were for veterans older than 55, the reevaluation would be deemed  unwarranted and the scheduled review date for considering reevaluation  would be cancelled. According to VBA officials, using this report helped  VBA identify and cancel about 70,000 potential reevaluations deemed  unnecessary, saving about $29 million. VBA plans to run similar reports  as needed to identify more reevaluations that could be cancelled,  according to officials.

Additionally, VBA officials said that they have data on the specific  conditions for which medical exams are ordered as part of the  reevaluation process. Ordering exams for reevaluations occurs after a  condition identified for potential reevaluation has been reviewed and a  decision has been made to proceed with a reevaluation. In particular,  VBA’s Exam Management System tracks exams ordered, including  exams for reevaluations, and provides information about the associated  conditions. However, this system does not provide information on the  outcome of a reevaluation decision based on the information from these  exams.

While VBA has some insight into conditions set to be reevaluated,  management lacks information on completed reevaluations, including (1)  trends and comparisons of certain reevaluated conditions and (2) rating  outcomes of reevaluation decisions for individual service-connected  conditions.

Reevaluation trends. VBA officials told us that they analyze trends on  the numbers of veterans who have had reevaluations. However, they said  they do not analyze reevaluation data to identify trends on whether  certain conditions are frequently or infrequently reevaluated, including for  conditions requiring reevaluation under VBA regulation. Further,  although VBA has a mechanism to identify potential reevaluations for  veterans with conditions requiring them, it is not analyzing the broader  universe of veterans with these conditions, according to VBA officials.  Such information could determine the extent to which conditions are  being identified for reevaluation as required as well as the outcomes or  results of these reevaluations. This trend information could also help VBA  determine whether claims processors are conducting reevaluations as  needed or required.

Reevaluation outcomes. VBA officials said that they do not analyze  information on the outcomes of reevaluation decisions for individual  conditions (i.e., whether a reevaluation resulted in an increase, decrease,  or no change to the rating of a particular condition). According to our  analysis of VBA data, reevaluations rarely result in changes to veterans’  combined ratings. Specifically, from fiscal years 2013 through 2018,  about 95 percent of reevaluations resulted in no changes to combined  ratings for veterans, with about 3 percent resulting in an increase and less  than 1 percent resulting in a decrease.

Combined ratings alone do not offer insight into what impact  reevaluations may have on ratings for individual conditions, including  which ones are improving as a result of treatment. Most veterans have  multiple conditions that contribute to a combined disability rating. VA  reported that in 2018 veterans receiving disability compensation had an  average of about five service-connected conditions. For those receiving  reevaluations, this circumstance means that although the rating of one  condition may decrease as a result of a reevaluation, the rating of another  condition may increase based on the claims processor’s review of the  medical evidence. As a result, the combined rating may not decrease  despite a decrease in the rating of an individual condition.

A recent report examining reevaluations for veterans with PTSD had  similar findings. In its review of a sample of veterans, the study found  that these veterans rarely saw a reduction in their individual rating for  PTSD. In cases where an individual rating was reduced, most saw no  reduction in their overall combined rating due to the fact that they had  other conditions whose ratings increased and thereby offset any  reduction.

According to VBA officials, the agency does not analyze data on trends in  reevaluated conditions or the outcomes of reevaluation decisions for  specific conditions because management has not expressed interest in  doing so. Further, officials said that these data are not stored together in  the database. Although analyzing these data and developing a report on  types of conditions reevaluated and their outcomes is feasible, according  to officials, doing so would require additional steps, including analyzing  the text of rating decisions.

According to VA regulation, reevaluations are intended to verify the  continued existence or the current severity of a disability. Federal  standards for internal control state that management should establish and  operate monitoring activities to evaluate the results of activities and  ensure that objectives are met with minimum wasted resources.  Moreover, they state that management should design a process that uses  the entity’s objectives and related risks to identify the information  requirements needed to achieve the objectives and address risks. These  standards also state that management should use quality information to  achieve the entity’s objectives.

Identifying the extent to which VBA is meeting these program objectives  and effectively managing resources is difficult without analyzing  information about the outcomes of reevaluations for specific conditions.  Such analysis could also identify trends indicating conditions with little or  no potential for a rating change or missed opportunities to target other  conditions likely to change as a result of reevaluations.

In recent years, VBA has focused its procedures on reducing the number  of unnecessary reevaluations and generally limiting the number of  reevaluations conducted overall. Using outcome information could allow  the agency to better target the agency’s resources and avoid the risk of  unnecessary reevaluations and burdening veterans.

Analyzing reevaluation trends and outcomes could also inform existing  VBA policy. For example, VA is updating the rating schedule with current  medical and earnings loss information, including adding conditions  requiring reevaluations. Analyzing information on which conditions are  reevaluated and identifying any trends in conditions that improve could  help inform future updates to the rating schedule or improve the policies  or practices for how the reevaluation process is implemented.

VBA Does Not Fully Use Performance Information to Help Improve the Reevaluation Process

VBA uses information to help gauge the timeliness and quality of  reevaluation decisions, but has not fully used information related to the  consistency of raters’ decisions to address potential training needs,  among other issues. VBA tracks its performance in providing veterans  with timely and accurate decisions on their disability compensation  benefits, and uses such information—including information on  reevaluations—to manage the claims process. VBA holds its claims  processing staff accountable for their timeliness and accuracy through  performance standards for regional office managers and individual claims  processors.

Timeliness. VBA measures and reports to Congress and the public  its total number of claims awaiting completion, including those that  have been backlogged (awaiting completion for more than 125 days).  According to VA, at of the end of fiscal year 2018 it had about 364,000  disability compensation rating claims awaiting completion. Of this  total, about 19,000 were reevaluations, of which fewer than 5 percent  were in the backlog. VBA uses additional timeliness measures to hold  regional offices accountable by tracking the timeliness of their work in  each of five steps or cycles in the claims process, as managed under  the National Work Queue (VBA’s system for distributing the claims  workload). For example, in fiscal year 2018, preparing a rating  decision for a reevaluation took an average of 1.76 days.

Quality. VA uses national, regional office, and individual-level data  from its accuracy reviews to oversee the quality of rating claims  decisions, including reevaluations. Each regional office is to meet the  national STAR issue-based target of 96 percent accuracy for the year.  For reevaluations, VBA reported both claim-based and issue-based  accuracy of about 95 percent for fiscal year 2018. According to VBA  officials, in response to a recommendation in the VA OIG’s report on  unwarranted reevaluations, in October 2018 VBA updated the STAR  national quality review checklist with additional questions on (1) the  need for a reevaluation, and (2) the timeframe for future reevaluation.  At the individual claims processor level, VA measures accuracy using  the results of Individual Quality Reviews as part of claims processors’  performance evaluations. For example, a rater is considered fully  successful by achieving 92 to 96 percent accuracy on Individual  Quality Reviews for a month, depending on the rater’s experience.  In fiscal year 2018, VBA reported that for Individual Quality Reviews,  claims processors had a 98.4 percent accuracy rate for reevaluations.  Overall, few reevaluations are reviewed because reevaluations are a  small proportion of VA’s claims workload. Specifically, of about  102,000 reevaluations completed in fiscal year 2018, about 1,500  were reviewed under STAR and about 10,000 were reviewed in  Individual Quality Reviews. In addition to using accuracy information  to measure regional office and individual performance, VBA holds  regional offices and individual claims processors responsible for  correcting their errors.

According to VBA officials, the agency uses information from its quality  reviews to provide additional guidance and training to regional offices.  VBA discusses quality review information, including trends in claims  processing errors, through newsletters and periodic conference calls with  regional office managers and quality review teams. For example, VBA  officials noted that they discussed reevaluation policies and guidance with  regional office staff on three occasions between May 2017 and May 2018.  Officials at the four regional offices we visited indicated that they  disseminated information on reevaluations to claims processors. For  example, one office’s quality review team provided additional training on  reevaluations to members of the claims processing teams. Quality review  team officials in each of the regional offices we visited told us that they  disseminate and reinforce guidance to claims processors through periodic  meetings, newsletters, or other mechanisms.

VBA, however, has not fully used available information about quality to  oversee and improve the reevaluation process. Specifically, VBA did not  use the results of a study it conducted to further identify and correct gaps  in raters’ knowledge of reevaluation processing guidance. This May 2018  study—part of VBA’s quality assurance efforts that include periodic  consistency reviews of specific claims processing issues—assessed how  consistently raters across regional offices understood VBA’s policies on  ordering reevaluations (see table 2).

The study team recommended VBA take two actions:  1.  Consider having experienced quality review team staff at regional  offices provide additional training on reevaluation guidance to raters.  2.  Consider reviewing reevaluation decisions at the seven lowest-scoring  offices because they were at high risk of inaccuracies.

While VBA provided regional offices with results of the May 2018  consistency study, the agency did not implement either recommendation.

VBA officials told us that they did not direct regional offices to provide  additional training because the agency expected the offices to use the  results of the consistency study to plan training on reevaluations for their  staff. However, VBA officials told us that not all regional offices provided  additional training on reevaluations. Quality review officials at the four  offices we visited—which included two of the seven offices the study team  identified for further review—told us that they did not provide additional  training. Officials at two offices said they had previously provided  guidance and training to claims processors on reevaluations.

VA’s goals are to ensure timely and accurate claims decisions for  veterans. Federal standards for internal control state that management  should establish monitoring activities, evaluate the results, and remediate  any deficiencies on a timely basis. Consistent with these standards,  GAO has previously reported that a key use of performance information is  to identify problems and take corrective actions, for example, by changing  agency guidance or by providing training.

By not implementing the study’s recommendations, VBA is missing an  opportunity to identify problems and their root causes as a guide to  corrective actions, including training or the improvement of training. Many  raters who are trained to make these decisions did not perform well on  the consistency study’s initial test. Exploring deficiencies associated with  this poor performance could position VA to better manage the  reevaluation process. In addition, resources spent in developing the study  and analyzing its results were not used as effectively as they could have  been.

VBA Has Not Clearly Defined Skill Sets and Training Needed to Determine When to Reevaluate Veterans’ Conditions

VBA Has Not Clearly Defined Knowledge, Skills, and Abilities for Staff Conducting Pre-Exam Reviews in the Reevaluation Process

VBA has recently updated its procedures manual to clarify who can  determine whether a reevaluation is needed, but has not outlined  guidance for the knowledge, skills, and abilities needed to perform these  tasks. As part of the reevaluation process to assess veterans’ conditions,  VBA procedures require claims processors in regional offices to conduct  a pre-exam review to determine whether a reevaluation is still appropriate  when its scheduled review date arrives (see fig. 3). For the reevaluation  process to work effectively, proper procedures must be in place to ensure  that claims processors can make informed decisions on whether to  reevaluate these conditions.

Until its recent update, VBA’s procedures manual stated that staff  deemed part of “the rating activity” (defined in the manual as staff  including raters who specialize in rating claims) were the only claims  processors who were permitted to conduct a pre-exam review to  determine whether a reevaluation is warranted. In February 2019, VBA  updated its procedures manual to clarify that raters or “locally designated  claims processors” may conduct this review. Officials said that Veterans  Service Representatives (VSR) may fill this role in some offices.

Although VBA’s procedures permit VSRs to conduct pre-exam reviews,  VSRs may not be qualified to do so, according to the OIG’s July 2018  report and VBA regional staff we interviewed in 2019. The OIG found that  VSRs were ordering exams without raters’ pre-exam reviews, resulting in  an estimated 15,500 unwarranted exams (about 29 percent of the cases  from the study’s review period). These exams were determined to be  unwarranted based primarily on exclusions identified in VA’s procedures  that exempt certain veterans from reevaluation (see text box). The report  found that, rather than sending claims to raters for pre-exam review,  VSRs were ordering exams despite not having the proper training and  experience to decide on whether a reevaluation was warranted, such as  the specialized knowledge needed to review medical evidence.

Officials in regional offices we visited expressed concern about VSRs  performing this role. Specifically, staff in three of the four regional offices  we spoke with—including raters, supervisors, quality assurance staff, and  managers—told us that raters do the pre-exam review in their respective  offices because they are the only staff qualified to perform this duty. For  example, raters have more experience and training than VSRs in  reviewing medical evidence to determine the need for a reevaluation,  according to officials from one office. In contrast, supervisors we spoke  with at another regional office told us they have opted to have VSRs do  the pre-exam review as a way to manage the claims workload and enable  raters to focus exclusively on rating claims. However, these supervisors  expressed concern that VSR reviews could have a negative impact on  quality.

VBA officials said they have not outlined guidance for the skills needed to  perform the pre-exam review. Rather, VBA officials said that they believe  it is most effective to allow the regional offices, which vary widely in size  and scope, to have discretion to identify staff to fill this role. Further, VBA  officials told us that the recent update to the agency’s procedures did not  reflect a policy change broadening which staff can do pre-exam reviews,  but rather clarified existing practice under which VSRs were already  permitted to perform this task. However, given the OIG findings that VSRs  performing this task resulted in many unwarranted exams, defining the  knowledge, skills, and abilities needed for the pre-exam review could  provide assurance that staff who do so are qualified. Federal standards  for internal control call for management to clearly assign responsibilities  and document internal controls, including who should carry out which  roles. Identifying the knowledge, skills and abilities needed by qualified  staff to carry out their responsibilities can also help management ensure  the entity’s objectives are met.

Providing flexibility for regional offices can ease implementation and  management of workloads, especially for offices with varied situations.  However, providing flexibility does not preclude VBA from outlining the  basic knowledge, skills, and abilities required to perform the pre-exam  review. Further, in our prior work we found that VBA has faced challenges  in defining roles for its staff, which has led to inconsistencies in the way  regional offices operate. We have also found that ambiguous policies  provided by other VA programs can pose risks to the quality of the  process. Without clarifying in VBA’s procedures manual which  knowledge, skills, and abilities are needed to fill roles in the reevaluation  process, VBA may be at risk of having unqualified staff continue to order  unwarranted reevaluations. This risk, in turn, could result in wasted  resources and an undue burden on veterans.

VBA Has Not Ensured Proper Training for Staff Conducting Pre-Exam Reviews

Despite recent changes to its procedures manual, VBA has not ensured  that its training program reflects the knowledge, skills, and abilities  needed for relevant staff to conduct pre-exam reviews. VBA oversees  national training requirements, including training related to reevaluations,  but defers to regional offices to manage other training needs. As entry- level staff, claims processors receive national training from VBA related to  their job duties. For raters, this initial training covers reevaluations,  including instruction on when and when not to schedule reevaluations,  and case studies exploring how to make reevaluation decisions based on  medical and other evidence, among other topics. VSRs may also receive  general training on reviewing and evaluating evidence and are introduced  to reevaluations as they learn about general claim development and  ordering exams. In addition to initial training, claims processors must  complete 40 hours of training per year consisting of 15 hours of training  mandated by VBA and 25 hours determined by each regional office. VBA  officials told us that regional offices vary in what training and when  delivered to their staff.

In addition to this general training, VBA officials told us that VA added  controls to the Veterans Benefits Management System (VBMS) system to  restrict claims processors’ ability to schedule potential reevaluations,  which could reduce the possibility of unqualified staff ordering  unwarranted exams during the pre-exam review. Specifically, these  controls prevent claims processors from scheduling review dates for  potential reevaluations when certain exclusions apply (such as that  outlined in VA regulation exempting from reevaluation veterans with the  minimum rating for a given condition). Further, claims processors have  the ability to request to override the restrictions when they believe a  reevaluation is warranted based on the circumstances of the case. These  override requests are reviewed by quality assurance staff, who may  approve or deny the requests.

Although these controls may impose some limits on ordering unwarranted  exams, they may not affect the ability of claims processors to order  reevaluations in circumstances where these exclusions do not apply and  for which they must use their discretion. For example, for veterans who  have migraine headaches and who do not fit any of the exclusion criteria,  no VBMS controls would restrict claims processors from ordering a  reevaluation even if it is not appropriate based on the medical evidence or  other circumstances of the case. For these controls and VBA’s  procedures to be effective, providing proper training to claims processors  making these decisions remains important.

VBA officials told us that they did not update training requirements as a  result of the recent update to procedures because this update did not  constitute a policy change. Rather, they said they revised the procedures  to align with the existing practice before the update, in which VSRs were  permitted to do pre-exam reviews. Further, officials said that each  regional office can designate qualified claims processors to perform the  pre-exam review and provide training as necessary. VBA officials also  said that they do not believe additional training is necessary for VSRs  who may be performing this role because the procedure for ordering  exams—a skill for which they have been trained—is the same for all types  of exams, including those for reevaluations.

Although VSRs receive training on the process of ordering an exam, VBA  officials confirmed that VSR coursework does not specifically cover the  pre-exam review in the reevaluation process. In contrast, raters receive  training on the process of deciding whether a reevaluation is warranted,  including reviewing medical evidence and applying exclusions in VBA’s  procedures. Further, staff in three of the four regional offices we spoke  with, including supervisors, quality assurance staff, and managers, said  that VSRs do not have the proper training for this task. For example, they  are not trained to review medical evidence to make an informed decision  about whether a reevaluation is still warranted, according to officials.  Similarly, the OIG found in its 2018 report, which reviewed a sample of  claims from March through August 2017, that VSRs were unfamiliar with  criteria used to determine whether or not an exam is necessary.

Federal standards for internal control highlight the importance of training  to develop the relevant knowledge, skills, and abilities needed for key  roles. We also have previously identified key practices for training and  development that suggest that agencies should have a strategy that  includes tracking and other control mechanisms to ensure that the  relevant employees receive training in line with their responsibilities.  Without ensuring that training reflects the relevant knowledge, skills, and  abilities needed by claims processors in VBA regional offices, VBA may  find these staff continue to make uninformed and incorrect reevaluation  decisions that are not aligned with VBA policy, guidance, and procedures.

VA spends substantial time, effort, and billions of dollars per year  providing disability compensation, health care, and other forms of  assistance that promote the wellness of veterans with service-connected  conditions. However, VA does not know whether these efforts improve  the health of these veterans on several fronts. While we are encouraged  by VA’s interest in considering ways to analyze health outcomes, VA has  not yet established a plan for addressing the identified research  challenges. Without a plan, VA will not be positioned to understand the  characteristics, needs, and health outcomes of veterans with service- connected conditions or how disability compensation and health care  work together to help them.

Disability reevaluations can shed light on whether veterans’ service- connected conditions have changed. However, the agency could take  additional steps to analyze outcome and other data on completed  reevaluations. Importantly, tracking and analyzing trends and outcomes  could shed light on an apparent contradiction: why the majority of recent  reevaluations resulted in no change in veterans’ combined ratings when  the regulations state that reevaluations generally should not be conducted  in these cases. Without these analyses, VA may be unaware of any  reevaluation trends, possible explanations for them, or need to recalibrate  guidance or resources to address these issues.

Reevaluations represent an investment of resources for VA and the  veterans who undergo them. Insights into the effectiveness of the  reevaluation process are thus critical for managing VBA’s workload and  informing agency policy. Specifically, while VBA tested raters’ knowledge  of reevaluation policies in its May 2018 consistency study, it missed opportunities to review reevaluation decisions in the offices at greatest  risk of making incorrect decisions, as recommended in the consistency  study report. Following up on the report’s findings could also provide  insights into root causes of errors in reevaluation decisions, which could  inform decisions about additional targeted training or improved guidance.

For veterans who show health improvements, VBA’s reevaluation process  can ensure they have the correct disability rating and associated benefit  payment. However, VBA could better mitigate the risks of making  unwarranted reevaluation decisions by clarifying guidance in its  procedures manual about the knowledge, skills, and abilities regional  office staff need to determine whether a reevaluation should be  conducted. Moreover, defining training requirements would help ensure  that claims processors who conduct reevaluations have the needed skill  sets and that their decisions are aligned with VBA policy and guidance.

Ultimately, by enhancing and linking existing information about service- connected conditions and health care and from the results of  reevaluations, VA could better understand the health outcomes of  veterans who have incurred or aggravated disabling conditions during  military service.

We are making the following five recommendations to VA:  The Secretary of Veterans Affairs should ensure that the Office of  Enterprise Integration develops a plan—including milestones and roles  and responsibilities for OEI, VBA, and VHA—to address identified  challenges that have hindered research on the health care outcomes for  service-connected conditions of veterans receiving disability  compensation. To align VA’s efforts with the goals of its 2018-2024  Strategic Plan, VA’s development of this plan should be completed and  ready for implementation by June 1, 2020. (Recommendation 1)

The Under Secretary for Benefits should develop and implement a  periodic analysis of program management data for trends in the individual  service-connected conditions being reevaluated as well as data on the  outcomes of reevaluations. (Recommendation 2)

The Under Secretary for Benefits should implement the two  recommendations in VBA’s May 2018 consistency study to provide  training on how to determine when a reevaluation is needed and review  reevaluation decisions for accuracy at the lowest-scoring offices and take  corrective action as needed. (Recommendation 3)

The Under Secretary for Benefits should clarify guidance in its procedures  manual regarding the knowledge, skills, and abilities needed to make  decisions on whether to reevaluate veterans for changes in their service- connected conditions. (Recommendation 4)

The Under Secretary for Benefits should align training requirements with  the knowledge, skills, and abilities needed for reviewing claims to decide  whether to conduct a reevaluation. (Recommendation 5)

We provided a draft of this report to the Department of Veterans Affairs  (VA) for review and comment. VA provided written comments that are  reproduced in appendix I. VA agreed with recommendations 1 and 2, and  concurred in principle with our other three recommendations. The  comment letter described steps the Veterans Benefits Administration  (VBA) plans to take, or is in the process of taking, to address the  recommendations. However, except for recommendations 1 and 2, VA’s  proposed actions would not fully address the underlying issues we  identified.

With regard to recommendation 1 to develop a plan to address  challenges to studying health outcomes, VA stated that the Office of  Enterprise Integration (OEI) will coordinate with VBA and the Veterans  Health Administration (VHA) to create an operational plan that addresses  challenges that have hindered research on health care outcomes for  service-connected conditions of veterans receiving disability  compensation. VA anticipates completing this plan by June 2020.

With regard to recommendation 2 to use information on reevaluations to  improve program management, VA stated that VBA plans to expand its  review of existing data and reports to analyze trends regarding which  service-connected conditions are identified for reevaluation, and review  the outcomes or results of these reevaluations. VBA plans to develop and  implement this effort by the end of June 2020.

With regard to recommendation 3 to implement the recommendations  from the 2018 consistency study, VA stated that VBA provided a reminder  to all regional offices about the availability of training resources on how to  determine when a reevaluation is needed. VA also stated that VBA  conducted another consistency study on this issue in August 2019 and  plans to inspect claims at the two lowest-scoring regional offices identified  in that study by January 15, 2020. We are encouraged by VBA’s plans to  use the results of the 2019 study by inspecting claims at the lowest- scoring offices. However, using the results of both the 2018 and 2019  studies would allow VBA to more fully identify and correct root causes of  any deficiencies, such as through additional training or the improvement  of training.

With regard to recommendation 4 to clarify guidance regarding the  specific knowledge, skills, and abilities staff need to determine when to  reevaluate disability claims, VA recognized the importance of having  appropriately skilled and trained employees to process reevaluations and  other claims. VA stated that each regional office identifies which  employees complete these reviews based on their staff expertise.  Further, VA stated that its Systematic Technical Accuracy Review (STAR)  results of 95 percent for reevaluations indicate that further action is not  needed. We continue to believe that flexibility for regional offices can be  balanced with assurance that staff with the appropriate knowledge, skills,  and abilities are conducting this work across regional offices. In addition,  the STAR accuracy rate provides limited information about the accuracy  of decisions to reevaluate claims, as discussed below. As noted in the  report, identifying the knowledge, skills and abilities needed by qualified  staff to carry out their responsibilities can help management ensure the  program’s objectives are met.

With regard to recommendation 5 to improve training for reevaluations,  VA stated that additional training on reevaluations is not needed because  its STAR accuracy rate for reevaluations is 95 percent. As noted in the  report, VBA’s STAR reviews a small percentage of all completed  reevaluations, and errors related to improperly ordered reevaluations are  not reflected in STAR accuracy scores. We believe that additional action  is needed to address our recommendation by ensuring staff are trained  appropriately on these procedures to correctly determine whether  reevaluations are needed. This additional training or guidance is  particularly needed given the results of VBA’s May 2018 and August 2019  consistency studies, the views of regional staff we talked with, and the  large volume of unwarranted exams.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Veterans Affairs, and other interested  parties. In addition, the report is available at no charge on the GAO  website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or curdae@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 II.

Appendix I: Comments from the Department of Veterans Affairs

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the contact named above, James Whitcomb (Assistant  Director), Dana Hopings (Analyst-in-Charge), Rachel Pittenger, and Greg  Whitney made key contributions to this report. Also contributing to this  report were Steven Campbell, Debra Draper, Alex Galuten, Sarah  Gilliland, Alison Grantham, Amber Gray, Gina Hoover, Aaron Karty, Diona  Martyn, Mimi Nguyen, Jessica Orr, Claudine Pauselli, Almeta Spencer,  Srinidhi Vijaykumar, and Erin Wurtemberger.

The Department of Veterans Affairs pays monthly compensation to veterans with disabling conditions caused or aggravated by their military service.

We found that more than half of the veterans receiving disability compensation used VA health care for their conditions. However, VA does not have a clear picture of whether these services improve veterans’ health. VA could also enhance its process for determining when to reevaluate possible changes in health conditions.

We made 5 recommendations, including that VA develop better research on health outcomes for veterans receiving disability pay and improve its reevaluation process.