GAO: VA Lacks Oversight on Mental Health Care
Behavioral health care is an important treatment option for veterans, especially those suffering from PTSD, anxiety, and any number of other common mental health issues. This includes services like talking to a therapist or getting medicine for these conditions. And not all veteran care is performed at VA facilities.
Many veterans get this help from providers in their local communities through a VA program called Community Care. This program is meant to make it easier and faster for veterans to get care outside the immediate VA system.
But a recent report from the government’s watchdog, the Government Accountability Office (GAO), found problems with VA oversight and management of this care. The report points out issues with handling veteran medical records and making sure community providers are trained on veteran needs, indicating less-than-ideal circumstances for many who need these important services.
The GAO Study on VA Behavioral Health Care
The GAO looked at how the VA checked on behavioral health referrals sent to community providers from late 2020 to late 2023. It included the following in its conclusion:
“We are making five recommendations to VA, including for it to establish goals and performance measures and monitor the extent to which medical documentation exchanges and core community provider trainings have been completed.”
The inquiry sought to determine how well the VA managed medical record transfers from private care providers and how it verifies community providers’ core training relevant to veterans’ needs. According to the GAO, the VA lacks oversight of these processes.
A central finding of the GAO concerns the flow of medical information. VA care relies on community providers promptly sending medical documentation to the Department of Veterans Affairs after treating a veteran. This informs VA healthcare teams about a veteran’s treatment, progress, and any changes. The GAO found that the VA does not consistently check whether this vital information exchange occurs across all its medical centers.
What the Government Accounting Office Reviewed
The GAO’s analysis showed a clear problem with missing medical records. The report says, “33 percent of referrals were missing records for initial visits.” This means that for many veterans who started mental health care with a community provider the VA sent them to, the VA didn’t have the medical record from that first meeting.
The report also states, “No data are available for final visits, so the extent to which those exchanges are completed is unknown.” This means the VA has no clear information on how often records from when a veteran finishes seeing a community provider are sent back.
Provider training issues abound at the VA. The GAO report says, “VA is not monitoring the extent to which community providers complete any of eight core trainings on opioid safety, suicide prevention, and other veteran-centric topics.”
Not checking implies the VA cannot effectively track whether community providers finish these important training classes. This raises worries about whether these providers have the needed knowledge to help veterans well. Veterans might have military experiences that require a special understanding.
The report found, “About 2 percent of the community providers with a behavioral health referral from fiscal years 2021 through 2023 had completed one or more of these trainings.” Only about 2 percent finishing training suggests many community providers in the network might not have learned about topics very important for veterans.
Does this imply a risk that veterans might get care from providers without special knowledge about veteran needs? Veterans with conditions like PTSD or TBI need certain types of therapy. It’s more effective from providers who have context, training, and/or experience with military life.
If community providers haven’t had the right training, they might not be ready to offer the most helpful care.
Fixing the Oversight Problem at the Department of Veterans Affairs
The GAO gave the VA five specific steps to take, including creating “guidance for VA medical centers’ efforts in obtaining final medical documentation after all visits provided to a veteran under each referral have been completed.” This directly addresses the fact that the GAO found no data on getting final visit records.
The GAO recommended creating “a process for regularly using performance information for VA medical centers in obtaining initial and final medical documentation from community providers to assess its progress toward established goals.”
The best VA response to these recommendations is to implement them.
At press time, there is no indicator that any steps have been taken to correct the issues noted in the report published on May 5, 2025. While that may change at a later date, many veterans today expect a greater sense of urgency on issues like these from the Department of Veterans Affairs.
As mentioned at the start of this article, according to the GAO official site:
“We are making five recommendations to VA, including for it to establish goals and performance measures and monitor the extent to which medical documentation exchanges and core community provider trainings have been completed. VA concurred with one recommendation and concurred in principle with the other four recommendations, as discussed in the report.”
This is an ongoing story.
About the author
Editor-in-Chief Joe Wallace is a 13-year veteran of the United States Air Force and a former reporter/editor for Air Force Television News and the Pentagon Channel. His freelance work includes contract work for Motorola, VALoans.com, and Credit Karma. He is co-founder of Dim Art House in Springfield, Illinois, and spends his non-writing time as an abstract painter, independent publisher, and occasional filmmaker.
