VA Disability Exams: Actions Needed to Improve Program Management

What GAO Found

In recent years, the Department of Veterans Affairs (VA) has significantly expanded the Veterans Benefits Administration’s (VBA) use of contractors to perform disability medical exams instead of relying on Veterans Health Administration (VHA) medical centers. According to VBA officials, VA’s policy is to continue using contractors for most exams. GAO previously identified sound practices agencies can use to plan for significant programmatic changes. However, VBA has not applied several of these practices to its plans for allocating workloads among its contractors and VHA medical centers. For example, VBA has not assessed potential risks to capacity and exam quality in allocating the bulk of exams to contractors. Employing such practices could help VBA identify potential risks stemming from this long-term program change and better plan for addressing future workload needs.

Percent of Disability Exams Performed by VBA Contractors and by VHA Medical Centers, Fiscal Years 2017-2021

Over time, VA has also permitted contractors to complete exams for more complex disability claims—such as Gulf War Illness—according to VBA officials, but VBA does not conduct targeted reviews specifically to assess the quality of the exam reports completed for these exams. VBA data show that exam reports for selected complex claims were returned to examiners for correction or clarification at about twice the rate that exam reports were returned overall. Disability medical examiners told GAO that these types of exams can be challenging. Without specifically assessing how well contractors perform on exams for complex claims, VBA is missing an opportunity to identify actions that could help ensure veterans receive high quality exams and that exam reports are completed correctly.

Why GAO Did This Study

This testimony summarizes the information contained in GAO’s March 2021 report, entitled VA Disability Exams: Better Planning Needed as Use of Contracted Examiners Continues to Grow (GAO-21-444T). This testimony also builds upon prior GAO reporting on VBA’s contract exam program in October 2018 (GAO-19-13).

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    In fiscal year (FY) 2020, GAO’s work yielded $77.6 billion in financial benefits, a return of about $114 for every dollar invested in GAO. We also identified 1,332 other benefits that led to improved services to the American people, strengthened public safety, and spurred program and operational improvements across the government. In addition, GAO reported on 35 areas designated as high risk due to their vulnerabilities to fraud, waste, abuse, and mismanagement or because they face economy, efficiency, or effectiveness challenges. In FY 2020 GAO’s High Risk Series products resulted in 168 reports, 26 testimonies, $54.2 billion in financial benefits, and 606 other benefits. In this year of GAO’s centennial, GAO’s FY 2022 budget request seeks to lay the foundation for the next 100 years to help Congress improve the performance of government, ensure transparency, and save taxpayer dollars. GAO’s fiscal year (FY) 2022 budget requests $744.3 million in appropriated funds and uses $50.0 million in offsets and supplemental appropriations. These resources will support 3,400 full-time equivalents (FTEs). We will continue our hiring focus on boosting our Science and Technology and appropriations law capacity. GAO will also maintain entry-level and intern positions to address succession planning and to fill other skill gaps. These efforts will help ensure that GAO recruits and retains a talented and diverse workforce to meet the priority needs of the Congress. In FY 2022, we will continue to support Congressional oversight across the wide array of government programs and operations. In particular, our science and technology experts will continue to expand our focus on rapidly evolving issues. Hallmarks of GAO’s work include: (1) conducting technology assessments at the request of the Congress; (2) providing technical assistance to Congress on science and technology matters; (3) continuing the development and use of technical guides to assess major federal acquisitions and technology programs in areas such as technology readiness, cost estimating, and schedule planning; and (4) supporting Congressional oversight of federal science programs. With our requested funding, GAO will also bolster capacity to review the challenges of complex and growing cyber security developments. In addition, GAO will continue robust analyses of factors behind rising health care costs, including costs associated with the ongoing COVID-19 Pandemic. Internally, the funding requested will make possible priority investments in our information technology that include the ability to execute transformative plans to protect data and systems. In FY 2022 GAO will continue to implement efforts to increase our flexibility to evolve IT services as our mission needs change, strengthen information security, increase IT agility, and maintain compliance. We will increase speed and scalability to deliver capabilities and services to the agency. This request will also help address building infrastructure, security requirements, as well as tackle long deferred maintenance, including installing equipment to help protect occupants from dangerous bacteria, viruses, and mold. As reported in our FY 2020 financial statements, GAO’s backlog of deferred maintenance on its Headquarters Building had grown to over $82 million as of fiscal year-end. Background GAO’s mission is to support Congress in meeting its constitutional responsibilities and to help improve the performance and ensure the accountability of the federal government for the benefit of the American people. We provide nonpartisan, objective, and reliable information to Congress, federal agencies, and to the public, and recommend improvements across the full breadth and scope of the federal government’s responsibilities. In fiscal year 2020. GAO issued 691 products, and 1,459 new recommendations. Congress used our work extensively to inform its decisions on key fiscal year 2020 and 2021 legislation. Since fiscal year 2000, GAO’s work has resulted in over: $1.2 trillion dollars in financial benefits; and 25,328 program and operational benefits that helped to change laws, improve public services, and promote sound management throughout government. As GAO recognizes 100 years of non-partisan, fact-based service, we remain committed to providing program and technical expertise to support Congress in overseeing the executive branch; evaluating government programs, operations and spending priorities; and assessing information from outside parties.
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  • Department of Energy: Improved Performance Planning Could Strengthen Technology Transfer
    In U.S GAO News
    The Department of Energy (DOE) and its national labs have taken several steps to address potential barriers to technology transfer—the process of providing DOE technologies, knowledge, or expertise to other entities. GAO characterized these barriers as (1) gaps in funding, (2) legal and administrative barriers, and (3) lack of alignment between DOE research and industry needs. For example, the “valley of death” is a gap between the end of public funding and start of private-sector funding. DOE partly addresses this gap with its Technology Commercialization Fund, which provides grants of $100,000 to $1.5 million to DOE researchers to advance promising technologies with private-sector partners. Further, DOE's Energy I-Corps program trains researchers to commercialize new technologies and to identify industry needs and potential customers. However, DOE has not assessed how many and which types of researchers would benefit from such training. Without doing so, DOE will not have the information needed to ensure its training resources target the researchers who would benefit most. Illustration of Funding Gap for Commercializing New Technologies DOE plans and tracks the performance of its technology transfer activities by setting strategic goals and objectives and annually collecting department-wide technology transfer measures, such as the number of patented inventions and licenses. However, the department does not have objective and measurable performance goals to assess progress toward the broader strategic goals and objectives it developed. For example, without a performance goal for the number of DOE researchers involved in technology transfer activities and a measure of such involvement, DOE cannot assess the extent to which it has met its objective to encourage national laboratory personnel to pursue technology transfer activities. Internal control standards for government agencies call for management to define objectives in measurable terms, either qualitative or quantitative, so that performance toward those objectives can be assessed. Moreover, DOE has not aligned the 79 existing measures that it collects with its goals and objectives, nor has it prioritized them. Some lab stakeholders said that collecting and reporting these measures is burdensome. Prior GAO work has found that having a large number of performance measures may risk creating a confusing excess of data that will obscure rather than clarify performance issues. Researchers at DOE and its 17 national labs regularly make contributions to new energy technologies, such as more efficient batteries for electric vehicles. Technology transfer officials at the labs help these researchers license intellectual property and partner with private-sector companies to bring these technologies to market. However, several recent reports have highlighted barriers and inconsistencies in technology transfer at DOE, including a 2015 commission report that found barriers related to the costs of collaboration and low maturity level of many DOE technologies. This report examines (1) steps DOE has taken to address barriers to technology transfer and (2) the extent to which DOE plans and tracks the performance of its technology transfer and commercialization activities. GAO analyzed DOE documents on technology transfer and spoke with officials at DOE and seven national labs, as well as with representatives of universities and private-sector companies. GAO selected labs across a range of DOE activities and based on their technology transfer activities. GAO recommends that DOE assess researchers' needs for commercialization training and develop objective, quantifiable, and measurable performance goals and a limited number of related performance measures for its technology transfer efforts. DOE concurred with the recommendations. For more information, contact Candice Wright at (202) 512-6888 or WrightC@gao.gov.
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  • Federal Court Finds Florida Tax Preparers in Contempt for Violating Court’s Preliminary Injunction
    In Crime News
    On Thursday, a federal court in the Southern District of Florida held two individuals, as well as the company they allegedly co-own, in contempt for violating a preliminary injunction that restricted their tax preparation activities. The court’s order notes defendants “admit that sufficient evidence exists to hold them in contempt of court for violating the preliminary injunction.”
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  • Owner of Medical Laboratory Sentenced to Prison for Filing False Tax Returns
    In Crime News
    A Shreveport, Louisiana, business owner was sentenced to 40 months in prison on Sept. 30, 2020, for filing false tax returns, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Justice Department’s Tax Division and Acting U.S. Attorney for the Western District of Louisiana Alexander C. Van Hook.
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  • Owner and Operator of India-Based Call Centers Sentenced to Prison for Scamming U.S. Victims out of Millions of Dollars
    In Crime News
    An Indian national was sentenced today to 20 years in prison followed by three years of supervised release in the Southern District of Texas for his role in operating and funding India-based call centers that defrauded U.S. victims out of millions of dollars between 2013 and 2016.
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  • Global Health Security: USAID and CDC Funding, Activities, and Assessments of Countries’ Capacities to Address Infectious Disease Threats before COVID-19 Onset
    In U.S GAO News
    Pour la version française de cette page, voir GAO-21-484. What GAO Found As of March 31, 2020, the U.S. Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC) had obligated a combined total of more than $1.2 billion and disbursed about $1 billion for global health security (GHS) activities, using funds appropriated in fiscal years 2015 through 2019. USAID and CDC supported activities to help build countries' capacities in 11 technical areas related to addressing infectious disease threats. The obligated funding supported GHS activities in at least 34 countries, including 25 identified as Global Health Security Agenda (GHSA) partner countries. U.S.-Supported Activities in Ethiopia to Strengthen Global Health Security U.S. officials' assessments of 17 GHSA partner countries' capacities to address infectious disease threats showed that at the end of fiscal year 2019, most countries had some capacity in each of the 11 technical areas but faced various challenges. U.S. interagency country teams produce biannual capacity assessments that USAID and CDC headquarters officials use to track the countries' progress. According to fiscal year 2019 assessment reports, 14 countries had developed or demonstrated capacity in most technical areas. In addition, the reports showed the majority of capacities in each country had remained stable or increased since 2016 and 2017. The technical area antimicrobial resistance showed the largest numbers of capacity increases—for example, in the development of surveillance systems. GAO's analysis of the progress reports found the most common challenges to developing GHS capacity were weaknesses in government institutions, constrained resources, and insufficient human capital. According to agency officials, some challenges can be overcome with additional U.S. government funding, technical support, or diplomatic efforts, but many other challenges remain outside the U.S. government's control. This is a public version of a sensitive report that GAO issued in February 2021. Information that USAID and CDC deemed sensitive has been omitted. Why GAO Did This Study The outbreak of Coronavirus Disease 2019 (COVID-19) in December 2019 demonstrated that infectious diseases can lead to catastrophic loss of life and sustained damage to the global economy. USAID and CDC have led U.S. efforts to strengthen GHS—that is, global capacity to prepare for, detect, and respond to infectious disease threats and to reduce or prevent their spread across borders. These efforts include work related to the multilateral GHSA initiative, which aims to accelerate progress toward compliance with international health regulations and other agreements. House Report 114-693 contained a provision for GAO to review the use of GHS funds. In this report, GAO examines, for the 5 fiscal years before the onset of the COVID-19 pandemic, (1) the status of USAID's and CDC's GHS funding and activities and (2) U.S. agencies' assessments, at the end of fiscal year 2019, of GHSA partner countries' capacities to address infectious disease threats and of challenges these countries faced in building capacity. GAO analyzed agency, interagency, and international organization documents. GAO also interviewed agency officials in Washington, D.C., and Atlanta, Georgia, and in Ethiopia, Indonesia, Senegal, and Vietnam. GAO selected these four countries on the basis of factors such as the presence of staff from multiple U.S. agencies. In addition, GAO analyzed interagency assessments of countries' capacities to address infectious disease threats in fiscal year 2019 and compared them with baseline assessments from 2016 and 2017. For more information, contact David Gootnick at (202) 512-3149 or gootnickd@gao.gov.
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  • Secretary Michael R. Pompeo and Israeli Prime Minister Benjamin Netanyahu
    In Crime Control and Security News
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    In Crime Control and Security News
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  • Medicaid Long-Term Services and Supports: Access and Quality Problems in Managed Care Demand Improved Oversight
    In U.S GAO News
    At the state and federal levels, GAO found weaknesses in the oversight of Medicaid managed long-term services and supports (MLTSS), which assist individuals with basic needs like bathing or eating. Through various monitoring approaches, six selected states identified significant problems in their MLTSS programs with managed care organization (MCO) performance of care management, which includes assessing beneficiary needs, authorizing services, and monitoring service provision to ensure quality and access to care. State efforts may not be identifying all care management problems due to limitations in the information they use to monitor MCOs, allowing some performance problems to continue over multiple years. Performance Problems in Managed Care Organization (MCO) Care Management, Identified by Selected States GAO found that the Centers for Medicare & Medicaid Services' (CMS) oversight of state implementation of its 2016 requirements, and of access and quality in MLTSS more broadly, was limited. This hinders the agency's ability to hold states and MCOs accountable for quality and access problems beneficiaries may face. Oversight did not detect quality and access problems. GAO identified cases where CMS learned about problems not through its regular oversight, but instead from beneficiary complaints, media reports, or GAO. CMS officials said that states had not reported these problems to the agency. Lack of national oversight strategy and assessment of problems in MLTSS. Weaknesses in oversight reflect a broader area of concern—namely, that CMS lacks a strategy for oversight. CMS also has not assessed the nature and extent of access and quality problems across states. Without a strategy and more robust information, CMS risks being unable to identify and help address problems facing beneficiaries. As of July 2020, CMS had convened a new workgroup focused on MLTSS oversight, though the goals and time frames for its work were unclear. An increasing number of states are using managed care to deliver long-term services and supports in their Medicaid programs, thus delegating decisions around the amounts and types of care beneficiaries receive to MCOs. Federal guidance requires that MLTSS programs include monitoring procedures to ensure the appropriateness of those decisions for this complex population, which includes adults and children who may have physical, cognitive, and mental disabilities. GAO was asked to review care management in MLTSS programs. Among other things, this report examines state monitoring of care management, and CMS oversight of state implementation of 2016 requirements related to MLTSS quality and access. GAO examined documentation of monitoring procedures and problems identified in six states selected for variation in program age and location. GAO reviewed federal regulations and oversight documents, interviewed state and federal Medicaid officials, and assessed CMS's policies and procedures against federal internal control standards. GAO is making two recommendations to CMS to (1) develop a national strategy for overseeing MLTSS, and (2) assess the nature and prevalence of MLTSS quality and access problems across states. CMS did not concur with the recommendations. GAO maintains the recommendations are warranted, as discussed in this report. For more information, contact at (202) 512-7114 or yocomc@gao.gov.
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  • Secretary Michael R. Pompeo With Bud Hedinger of Good Morning Orlando on WFLA Orlando
    In Crime Control and Security News
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  • Department of State Offers Reward Increase for Information to Bring Transnational Criminal to Justice
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