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Review of VHA's Patient-Centered Community Care (PC3) Provider Network Adequacy

Report Information

Issue Date
Report Number
15-00718-507
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Audit
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG assessed the adequacy of Patient-Centered Community Care (PC3) provider networks developed under Veterans Health Administration’s (VHA) contracts valued at approximately $9.4 billion. We found inadequate PC3 provider networks contributed significantly to VA medical facilities’ limited use of PC3. VHA spent $3.8 million of its $2.8 billion FY 2014 non VA care (NVC) budget (0.14 percent) on PC3. During the first 6 months of FY 2015, VHA’s PC3 purchases increased but still constituted less than 5 percent of its NVC expenditures. VHA staff attributed the limited use of PC3 to inadequate provider networks that lacked sufficient numbers and mixes of health care providers in the geographic locations where veterans needed them. VA medical facility staff considered the PC3 networks inadequate because PC3 networks lacked needed specialty care providers; returned authorizations had to be re-authorized through NVC and increased veterans’ wait times for care; and NVC provided veterans more timely care than PC3. VHA could not ensure the development of adequate PC3 provider networks because it lacked an effective governance structure to oversee the Chief Business Office’s planning and implementation of PC3; the Chief Business Office lacked an effective implementation strategy for the roll-out of PC3; and neither VHA nor the PC3 contractors maintained adequate data to measure and monitor network adequacy. We recommended the Under Secretary for Health strengthen controls over the monitoring of PC3 network adequacy and ensure adequate implementation and monitoring plans are developed for future complex healthcare initiatives.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensure the establishment of an adequate governance structure to oversee and improve Patient-Centered Community Care management and operations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensure adequate implementation and performance monitoring plans are developed for future high-dollar, complex health care initiatives.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health assess where Patient-Centered Community Care provider networks are inadequate and develop action plans to improve provider networks that are unable to provide health care services at the specific geographic locations identified.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensure the Patient-Centered Community Care Quality Assurance Surveillance Plan is revised to address the monitoring and measurement of network adequacy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health require the input of National Provider Identifier information for rendering providers in the Fee Basis Claims System to ensure adequate data are available for program evaluation and planning.