VA Health Care: Actions Needed to Improve Oversight of Graduate Medical Education Reimbursement

What GAO Found

The Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) provides training to more than 45,000 medical and dental residents annually through its Graduate Medical Education (GME) program. VHA has established policy for its GME program that details many roles and responsibilities for overseeing VA medical facilities’ reimbursements to affiliated academic institutions for residents’ salaries and benefits. However, this policy does not define key roles and responsibilities for VHA’s central office components, its regional networks, or its medical facilities. For example, VHA’s regional networks do not have defined roles and responsibilities for overseeing GME disbursements—contributing to noninvolvement or inconsistent involvement in disbursement agreement oversight. VHA officials reported that they are in the process of updating disbursement agreement policy, but did not indicate if the updates would address all identified concerns.

While VHA officials said that VHA’s two disbursement agreement oversight mechanisms—facility periodic audits and the Resident Disbursement Audit Process (ReDPro) checklist—are meant to have distinct but complementary purposes, GAO found that VHA policy, guidance, and the tools distributed for these oversight mechanisms did not reflect the distinct purposes officials described. VHA officials said that periodic audits are intended to be a first level of defense and to review actual payments to affiliates, whereas the ReDPro checklist is intended to be a second level of defense, aimed at reviewing the process to see if the rules related to disbursement agreements are being followed by VA medical facilities. However, the ReDPro checklist tool and VHA’s recommended periodic audit tool have numerous areas of overlap, including duplicative questions. This overlap causes inefficiencies and unnecessary burden on VA medical facility staff.

GAO also found additional weaknesses in the tools, guidance, and training for the two oversight mechanisms. For example, GAO found

  • an unclear ReDPro checklist tool, along with insufficient guidance and training related to conducting the ReDPro reviews. Officials from eight of 13 facilities in GAO’s review indicated that the ReDPro checklist instructions were unclear regarding appropriate supporting documents for checklist responses. These weaknesses contributed to errors and inconsistencies in ReDPro responses.
  • the lack of a standard audit tool, and inadequate guidance and training for periodic audit teams that contributed to problematic inconsistencies in the methodologies used by the audit teams and deficiencies in some of the audits conducted. Officials from 10 of 13 facilities in GAO’s review indicated that they would benefit from more tools, guidance, or training related to conducting periodic audits.

These weaknesses limit the effectiveness of VHA’s oversight mechanisms, and put VHA at increased risk of both not being able to identify and correct facilities’ lack of adherence to disbursement agreement policy and of possible improper payments to GME affiliates.

Why GAO Did This Study

Under VHA’s GME program, VA medical facilities use disbursement agreements to reimburse affiliated academic institutions for residents’ salaries and benefits. VHA developed policy related to establishing and administering disbursement agreements, but audits have found that facilities have not always adhered to VHA policy—resulting in improper payments to affiliates.

GAO was asked to review VHA policies and procedures related to reimbursements to affiliates for GME. This report examines (1) oversight roles and responsibilities for GME disbursement agreements and (2) VHA’s mechanisms for ensuring VA medical facilities adhere to policy.

GAO reviewed relevant VHA documents and federal internal control standards and interviewed VHA officials. GAO also reviewed ReDPro checklist responses and documentation from 13 VA medical facilities—selected based on factors including geographic variation, GME program size, and number of affiliates. GAO also visited four of the 13 facilities and interviewed officials at the other nine facilities.

What GAO Recommends

GAO is making seven recommendations to VA to define key roles in policy, reduce overlap between the ReDPro checklist and facility periodic audits, and improve the oversight mechanisms’ tools, guidance, and training. VA concurred with GAO’s recommendations.

For more information, contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov.

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    In reaction to falling domestic oil prices due to the COVID-19 pandemic, the Bureau of Land Management (BLM) developed a temporary policy in spring 2020 for oil and gas royalty relief. The policy aimed to prevent oil and gas wells from being shut down in way that could lead to permanent losses of recoverable oil and gas. During March through June 2020, BLM gave companies the opportunity to apply for a reduction in the royalty rates for certain oil and gas leases on federal lands. BLM approved reductions from 12.5 percent of total revenue on oil and gas sold from those leases to an average of less than 1 percent for a period of 60 days. However, BLM did not establish in advance that royalty relief was needed to keep applicants' wells operating, according to BLM officials. BLM also did not assess the extent to which the temporary policy kept oil and gas companies from shutting down their wells or the amount of royalty revenues forgone by the federal government. By evaluating the extent to which the policy met BLM's objective of preventing unrecoverable loss of oil and gas resources–and likely costs, such as forgone revenues—BLM could better inform its decisions about granting royalty relief that provides a fair return to the government, should the agency decide to consider such relief in the future. BLM officials told GAO that BLM state offices implementing the temporary policy for royalty relief made inconsistent decisions about approving applications for relief because the temporary policy did not supply sufficient detail to facilitate uniform decision-making. The officials added that their state offices did not have recent experience in processing applications for oil and gas royalty relief. Several of the officials had never received or processed royalty relief applications. In addition, GAO found that ongoing guidance for processing royalty relief decisions—within BLM's Fees, Rentals and Royalties Handbook , last revised in 1995—also does not contain sufficient instructions for approving royalty relief. For example, the handbook does not address whether to approve applications in cases where the lease would continue to be uneconomic, even after royalty relief. As a result, some companies that applied for royalty relief were treated differently, depending on how BLM officials in their state interpreted the policy and guidance. In particular, officials from two state offices told GAO they denied royalty relief to applicants because the applicants could not prove that royalty relief would enable their leases to operate profitably. However, two other state offices approved royalty relief in such cases. The fifth state office denied both of the applications it received for other reasons. BLM's existing royalty relief guidance did not address this issue, and BLM's temporary policy did not supply sufficient detail to facilitate uniform decision-making in these situations. BLM's directives manual states that BLM should provide BLM employees with authoritative instructions and information to implement BLM programs and support activities. Until BLM updates the royalty relief guidance, BLM cannot ensure that future relief decisions will be made efficiently and equitably across the states and provide a fair return to the federal government. BLM manages the federal government's onshore oil and gas program with the goals of facilitating safe and responsible energy development while providing a fair return for the American taxpayer. In April 2020, oil and gas producers faced financial challenges from a drop in demand for oil during the COVID-19 pandemic. If oil and gas prices decline, it places financial stress on oil and gas companies, thereby increasing bankruptcies and the risk of wells being shut down. BLM developed a temporary policy to provide oil and gas companies relief from royalties that they owe to the federal government when they sell oil and gas produced on federal lands. This testimony discusses (1) BLM's development of the temporary policy for royalty relief and what is known about the policy's effects, and (2) BLM's implementation of this policy across relevant states. To do this work, GAO reviewed BLM documents; analyzed royalty data; and interviewed BLM officials from headquarters and the five BLM state offices with jurisdiction over states that account for 94 percent of royalties from oil and gas production on federal lands. GAO is making two recommendations. BLM should (1) evaluate the effects of its temporary royalty relief policy and use the results to inform its ongoing royalty relief program, and (2) update its guidance to provide consistent policies for royalty relief.  For more information, contact Frank Rusco at (202) 512-3841 or ruscof@gao.gov.
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  • Sixth Former Tennessee Corrections Officer Pleads Guilty to Federal Offenses Arising out of a Cover Up of Staff Assault of an Inmate
    In Crime News
    Former Tennessee Department of Corrections (TDOC) Corporal Tommy Morris, 29, pleaded guilty to conspiring to cover up the beating of an inmate and to encouraging other officers to provide false information to investigators, the Justice Department announced today.
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  • Indian Health Service: Actions Needed to Improve Oversight of Provider Misconduct and Substandard Performance
    In U.S GAO News
    The Indian Health Service's (IHS) policies related to provider misconduct and substandard performance outline several key aspects of oversight, such as protecting children against sexual abuse by providers, ethical and professional conduct, and processes for managing an alleged case of misconduct. Although the Department of Health and Human Services (HHS) or IHS headquarters have established most of these policies, area offices that are responsible for overseeing facility operations and facilities, such as hospitals, may develop and issue their own policies as long as they are consistent with headquarters' policies, according to officials. Although some oversight activities are performed at IHS headquarters, IHS has delegated primary responsibility for oversight of provider misconduct and substandard performance to the area offices. However, GAO found some inconsistencies in oversight activities across IHS areas and facilities. For example, Although all nine area offices require that new supervisors attend mandatory supervisory training, most area offices provided additional trainings related to provider misconduct and substandard performance. The content of these additional trainings varied across area offices. For example, three area offices offered training on conducting investigations of alleged misconduct, while other area offices did not. Officials from IHS headquarters told GAO they do not systematically review trainings developed by the areas to ensure they are consistent with policy or IHS-wide training. Facility governing boards—made up of IHS area office officials, including the Area Director, and facility officials, such as the Chief Executive Officer—are responsible for overseeing each facility's quality of and access to care. They generally review information related to provider misconduct and substandard performance. However, there is no standard format used by governing boards to document their review, making it difficult to determine the extent this oversight is consistently conducted. In some cases, there was no documentation by governing boards of a discussion about provider misconduct or substandard performance. For example, none of the seven governing board meeting minutes provided from one area office documented their discussion of patient complaints. In other cases, there was detailed documentation of the governing board's review. Additionally, governing boards did not always clearly document how or why an oversight decision, such as whether to grant privileges to a provider, had been made based on their review of available information. These inconsistencies in IHS's oversight activities could limit the agency's efforts to oversee provider misconduct and substandard performance. For example, by not reviewing trainings developed by area offices, IHS headquarters may also be unable to identify gaps in staff knowledge or best practices that could be applied across area offices. Addressing these inconsistencies would better position the agency to effectively protect patients from abuse and harm resulting from provider misconduct or substandard performance. IHS provides care to American Indians and Alaska Natives (AI/AN) through a system of federally and tribally operated facilities. Recent cases of alleged and confirmed misconduct and substandard performance by IHS employees have raised questions about protecting the AI/AN population from abuse and harm. For example, in February 2020, a former IHS pediatrician was sentenced to five consecutive lifetime terms for multiple sex offenses against children. Several studies have been initiated or completed in response, and IHS has reported efforts to enhance safe and quality care for its patients. GAO was asked to review IHS oversight of misconduct and substandard performance. This report (1) describes IHS policies related to provider misconduct and substandard performance and (2) assesses IHS oversight of provider misconduct and substandard performance. GAO reviewed policies and documents, including minutes from 80 governing board meetings from January 2018 to December 2019. GAO also interviewed IHS officials from headquarters, all nine area offices with two or more federally operated facilities, and two federally operated facilities. GAO is making three recommendations, including that IHS should establish a process to review area office trainings as well as establish a standard approach for documenting governing board review of information. HHS concurred with these recommendations. For more information, contact Jessica Farb at (202) 512-7114 or farbj@gao.gov.
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  • Navy Shipyards: Actions Needed to Address the Main Factors Causing Maintenance Delays for Aircraft Carriers and Submarines
    In U.S GAO News
    The Navy's four shipyards completed 38 of 51 (75 percent) maintenance periods late for aircraft carriers and submarines with planned completion dates in fiscal years 2015 through 2019, for a combined total of 7,424 days of maintenance delay. For each maintenance period completed late, the shipyards averaged 113 days late for aircraft carriers and 225 days late for submarines. Maintenance Delays at Navy Shipyards for Fiscal Years 2015 through 2019 Unplanned work and workforce factors—such as shipyard workforce performance and capacity (having enough people to perform the work)—were the main factors GAO identified as causing maintenance delays for aircraft carriers and submarines. The Navy frequently cited both factors as contributing to the same days of maintenance delay. Unplanned work—work identified after finalizing maintenance plans—contributed to more than 4,100 days of maintenance delays. Unplanned work also contributed to the Navy's 36 percent underestimation of the personnel resources necessary to perform maintenance. The workforce factor contributed to more than 4,000 days of maintenance delay on aircraft carriers and submarines during fiscal years 2015 through 2019. The Navy has taken steps but has not fully addressed the unplanned work and workforce factors causing the most maintenance delays. First, the Navy updated planning documents to improve estimates and plans to annually update these data, but knowing whether changes improve results may take several years. Second, the Navy has consistently relied on high levels of overtime to carry out planned work. GAO's analysis found that high overtime among certain production shops, such as painting or welding, averaged from 25 to 32 percent for fiscal years 2015 through 2019, with peak overtime as high as 45 percent. Furthermore, shipyard officials told us that production shops at all four shipyards are working beyond their capacity. Overtime at such rates has been noted as resulting in diminished productivity. Third, the Navy initiated the Shipyard Performance to Plan initiative in the fall of 2018 to address the unplanned work and workforce factors, but it has not yet developed 13 of 25 planned metrics that could improve the Navy's understanding of the causes of maintenance delays. In addition, the Shipyard Performance to Plan initiative does not include goals, milestones, and a monitoring process along with fully developed metrics to address unplanned work and workforce weaknesses. Without fully developing metrics and implementing goals, action plans, milestones, and a monitoring process, the shipyards are not likely to address unplanned work and workforce weaknesses and the Navy is likely to continue facing maintenance delays and reduced time for training and operations with its aircraft carriers and submarines. For fiscal years 2015 through 2019, the Navy spent $2.8 billion in capital investments to address shipyard performance, among other things. However, the shipyards continue to face persistent and substantial maintenance delays that hinder the readiness of aircraft carriers and submarines. The Senate Armed Services Committee, in a report accompanying a bill for the National Defense Authorization Act for Fiscal Year 2019, included a provision for GAO to review Navy shipyards' performance. GAO evaluated the extent to which the Navy (1) completed maintenance at its shipyards on time on aircraft carriers and submarines in fiscal years 2015 through 2019, (2) has identified the main factors leading to maintenance delays, and (3) has addressed the main factors affecting any delays in that maintenance. GAO reviewed data related to Navy shipyard maintenance for fiscal years 2015 through 2019, analyzed factors contributing to delays and plans to address them, visited all four Navy shipyards, and met with Navy and shipyard officials. GAO is making three recommendations to the Navy, including updating workforce planning requirements to avoid the consistent use of overtime; completing the development of shipyard performance metrics; and developing and implementing goals, action plans, milestones, and monitoring results. The Navy concurred with all three recommendations. For more information, contact Diana Maurer, (202) 512-9627, MaurerD@gao.gov, or Asif A. Khan, (202) 512-9869, KhanA@gao.gov. 
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  • Correctional Sergeant and Correctional Officer Indicted for Inmate Abuse, Obstruction of Justice
    In Crime News
    A federal grand jury in Alabama returned a five-count indictment today charging two Alabama men, an Alabama Department of Corrections (ADOC) sergeant and corrections officer with assaulting an inmate at ADOC’s Staton Correctional Facility and making false statements following the assault.
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  • North Carolina Woman Sentenced for Production and Distribution of Child Pornography
    In Crime News
    A North Carolina woman was sentenced Monday to 50 years in prison followed by 20 years of supervised release for production and distribution of child pornography.
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  • Hospital Researcher Sentenced to Prison for Conspiring to Steal Trade Secrets and Sell to China
    In Crime News
    An Ohio man was sentenced yesterday to 33 months in prison for conspiring to steal exosome-related trade secrets concerning the research, identification and treatment of a range of pediatric medical conditions.
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    In Travel
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  • Pennsylvania Biofuel Company and Owners Sentenced on Environmental and Tax Crime Convictions Arising out of Renewable Fuels Fraud
    In Crime News
    Two biofuel company owners were sentenced to prison for conspiracy and making false statements to the U.S. Environmental Protection Agency (EPA) and conspiracy to defraud the IRS and preparing a false tax claim.
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  • Maryland Man Pleads Guilty to Submitting False Claim to Steal Funds Intended for Afghanistan Reconstruction
    In Crime News
    A Maryland man pleaded guilty today to filing a false claim for his role in a scheme to divert hundreds of thousands of dollars in State Department funds to his own use.
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  • Virginia Tax Preparer Sentenced to More Than Two Years in Prison for Preparing False Returns
    In Crime News
    A Newport News, Virginia, tax return preparer was sentenced to 27 months in prison for preparing false tax returns, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Justice Department’s Tax Division and U.S. Attorney G. Zachary Terwilliger for the Eastern District of Virginia.
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  • The Sentencing of Russian Opposition Figure Aleksey Navalny
    In Crime Control and Security News
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    In Crime Control and Security News
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