Program Profile
The Health Care Benefits Program (commonly referred to as the Treatment Benefits Program) provides eligible Veterans and other qualified recipients with funding to access necessary health care benefits. The Program is complex and is comprised of fourteen categories of benefits/services which include hundreds of benefits and services to meet a variety of needs. In 2016–17, program expenditures totaled approximately $308 Million and there were almost 80,000 Veterans accessing benefits. The Program is administered by Veterans Affairs Canada (VAC) field office staff and through a third-party health care processor with support from numerous areas within VAC. The Treatment Benefits Program Management Unit is responsible for the management of the Program.
Evaluation Purpose and Background
The Evaluation of the Health Care Benefits (Treatment Benefits) Program Management Function was conducted between June 2017 and January 2018. The purpose of the evaluation was to assess the operational efficiency of the Treatment Benefits Program Management Function and to provide opportunities for improvement. The scope period for the evaluation was April 2014 to September 2017. The evaluation approach was formative in nature and was a process and utilization-focused evaluation. Multiple lines of evidence were used as part of the evaluation methodologies, primarily: document review, interviews, data analysis, and site visits/work observation. The main limitation of the evaluation was that limited management data was available to support an assessment of activities and outputs and the reliance on self-reported workload.
Defining Program Management
Based on a review of numerous sources, program management is considered to be the management of interrelated program components in order to achieve synergies and keep components on track to deliver expected objectives and outcomes. Program management requires emphasis on strategic thinking, analysis, and relationship building.
Evaluation Findings
The evaluation team found that there are opportunities to improve the Treatment Benefits program management governance structure. As a result of requirements to focus on operational activities, recent turnovers in staff, changes in organizational structures, and a continually evolving health care environment, there is a need to refocus the program management function and determine objectives, priorities, and associated roles and responsibilities required to achieve desired program results. A roles and responsibilities document had not been updated since approximately 2010 and priorities, lessons learned, and risk areas were being informally documented/discussed.
The Benefits Review Committee is another key component of the Program’s governance structure. This committee provides a fundamental function for benefit and service discussions and changes, and provides an opportunity for transparent and evidence based decision making by stakeholders. There have been ongoing discussions regarding the committee’s terms of reference for a number of months and there has not been an official committee meeting with the whole quorum of members since 2016. The evaluation team also noted opportunities where the committee could be capitalized on to inform potential issue areas and to drive data/trend analysis for the Program.
At the time of the evaluation, the Treatment Benefits Program Management Unit had seen a significant departure in knowledgeable and experienced staff, and operational work was taking precedent over strategic management work (issues affecting Veterans are considered highest priority). Due to the focus on operational requirements and a turnover in staff, there has been limited data and trend analysis conducted by the Treatment Benefits Program Management Unit. Ongoing monitoring and reporting would support program performance measurement and help identify issues and trends that could improve program delivery and management.
The benefit grids are the basis of rules which directly support the delivery of benefits and services to Veterans. The last official review of the grids was completed between 2008 and 2010. In an ever-evolving health care environment, there is a need for more frequent reviews of the eligible treatment benefits and services and the supporting approval requirements.
Evaluation results suggest that short-term additional staffing could allow the Treatment Benefits Program Management Unit to analyze potential issues/risk areas, work on a medium to long-term plan, and therefore improve program management and delivery.
Conclusions
The governance structure of the Treatment Benefits Program Management Unit would benefit from updates to better support effective and efficient program management. A Treatment Benefits Program roles and responsibilities document requires updates. Ongoing discussions regarding the Benefit Review Committee’s purpose and membership roles, unsettled terms of reference, and a lack of regular meetings are also impacting the efficient and effective delivery of the Program.
More focus on strategic areas would benefit Veterans and VAC staff by updating guidance documents and supporting tools (such as the benefit grids) and therefore reducing the number of escalated enquiries.
Due to a lack of management information, the evaluation team is unable to confirm that additional resources would fix all issues, or that resources would be required on a long-term basis; however, the evaluation results suggest that the Treatment Benefits Program Management Unit would benefit from short-term staffing. The Unit first needs to formalize its governance structure, and then determine resources required to meet the established goals and priorities of the Program.
Recommendations
The evaluation findings and conclusions resulted in the following recommendations:
Recommendation 1:
It is recommended that the Director General, Service Delivery and Program Management improve the Program governance structure by:
- Updating the Treatment Benefits Roles and Responsibilities document to reflect changes in the organizational structure, roles and responsibilities of non-program unit staff and relevant committees, program unit objectives, key activities and outputs, and priorities;
- Producing a mid to long-term strategic and operational plan for the Treatment Benefits Program Management Unit, including resource needs, timelines, goals and linkages to Treatment Benefit Program priorities; and
- Sharing the above noted documents with departmental staff and third-party health claims processing staff.
Recommendation 2:
It is recommended that the Assistant Deputy Minister, Service Delivery finalize the Benefits Review Committee Terms of Reference (including membership roles and committee purpose), communicate the document with departmental staff and third-party health claims processing staff, and ensure that regular meetings occur on a go-forward basis.
Recommendation 3:
It is recommended that the Assistant Deputy Minister, Service Delivery work in collaboration with relevant areas across the department to strengthen the collection and analysis of data to support the management of the Treatment Benefits Program (such as performance measurement, risk areas, trend analysis, and regular monitoring of benefit specific data).
Recommendation 4:
It is recommended that the Director General, Service Delivery and Program Management implement a cycle of benefit reviews to ensure they are updated on a continuous and efficient basis.