VA and DOD Health Care
Opportunities to Maximize Resource Sharing Remain Gao ID: GAO-06-315 March 20, 2006The National Defense Authorization Act for Fiscal Year 2003 required that the Departments of Veterans Affairs (VA) and Defense (DOD) implement programs referred to as the Joint Incentive Fund (JIF) and the Demonstration Site Selection (DSS) to increase health care resource sharing between the departments. The act requires GAO to report on (1) VA's and DOD's progress in implementing the programs. GAO also agreed with the committees of jurisdiction to report on (2) the actions taken by VA and DOD to strengthen resource sharing and opportunities to improve upon those actions and (3) whether VA and DOD performance measures are useful for evaluating progress toward achieving health care resource-sharing goals.
VA and DOD are making progress in implementing two programs required by legislation in December 2002 to encourage health care resource sharing and collaboration--JIF and DSS. While JIF projects experienced challenges because of delays resulting from the initial absence of funding mechanisms and, in some cases, the need for additional acquisition and construction approvals, as of December 2005, 7 of 11 selected 2004 projects were operational. The DSS program also experienced challenges as some sites reported difficulty putting together project submission packages, noting confusion over the timelines and approval process as well as frustration with the amount of paperwork and rework required. Nonetheless, as of December 2005, 7 of the 8 DSS projects were operational. However, the Joint Executive Council (JEC) and Health Executive Council (HEC), VA and DOD entities established to facilitate collaboration and health care resource sharing between the departments, have not established a plan to measure and evaluate the advantages and disadvantages of DSS projects--information that will be useful for determining if projects that produce cost savings or enhance health care delivery efficiencies can be replicated systemwide. VA and DOD are creating mechanisms that support the potential to increase collaboration, sharing, and coordination of management and oversight of health care resources and services. The departments have taken steps to create interagency councils and workgroups to facilitate collaboration and sharing of information, establish working relationships among their leaders, and develop communication channels to further health care resource sharing. In addition, the departments developed a Joint Strategic Plan outlining six goals. However, JEC and HEC have not seized upon a number of opportunities to further collaboration and coordination. For example, JEC and HEC have not developed a system for collecting and monitoring information on the health care services that each department contracts for from the private sector--such as individual VA medical center or military treatment facility contracts for dialysis, laboratory services, or magnetic resonance imaging. If such a system were in place, the departments could use it to identify services that could be exchanged from one another or possibly obtain better contract pricing through joint purchasing of services, thus promoting systemwide cost savings and efficiencies. Furthermore, JEC and HEC have not directed that a joint nationwide market analysis be conducted to obtain information on what their combined future workloads will be in the areas of services, facilities, and patient needs. VA and DOD lack performance measures that would be useful for evaluating how well they are achieving their health care resource-sharing goals. For example, of the 30 measures contained in the departments' joint strategic plan, 5 were not developed at the time the plan was issued and 11 lacked longitudinal information. For the remaining 14 that require periodic measurement, there was variation in the rigor or specificity in the types of data to be collected or the analysis to be performed.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
March 2006:
VA and DOD Health Care:
Opportunities to Maximize Resource Sharing Remain:
GAO-06-315:
GAO Highlights:
Highlights of GAO-06-315, a report to congressional committees:
Why GAO Did This Study:
The National Defense Authorization Act for Fiscal Year 2003 required
that the Departments of Veterans Affairs (VA) and Defense (DOD)
implement programs referred to as the Joint Incentive Fund (JIF) and
the Demonstration Site Selection (DSS) to increase health care resource
sharing between the departments. The act requires GAO to report on (1)
VA‘s and DOD‘s progress in implementing the programs. GAO also agreed
with the committees of jurisdiction to report on (2) the actions taken
by VA and DOD to strengthen resource sharing and opportunities to
improve upon those actions and (3) whether VA and DOD performance
measures are useful for evaluating progress toward achieving health
care resource-sharing goals.
What GAO Found:
VA and DOD are making progress in implementing two programs required by
legislation in December 2002 to encourage health care resource sharing
and collaboration”JIF and DSS. While JIF projects experienced
challenges because of delays resulting from the initial absence of
funding mechanisms and, in some cases, the need for additional
acquisition and construction approvals, as of December 2005, 7 of 11
selected 2004 projects were operational. The DSS program also
experienced challenges as some sites reported difficulty putting
together project submission packages, noting confusion over the
timelines and approval process as well as frustration with the amount
of paperwork and rework required. Nonetheless, as of December 2005, 7
of the 8 DSS projects were operational. However, the Joint Executive
Council (JEC) and Health Executive Council (HEC), VA and DOD entities
established to facilitate collaboration and health care resource
sharing between the departments, have not established a plan to measure
and evaluate the advantages and disadvantages of DSS
projects”information that will be useful for determining if projects
that produce cost savings or enhance health care delivery efficiencies
can be replicated systemwide.
VA and DOD are creating mechanisms that support the potential to
increase collaboration, sharing, and coordination of management and
oversight of health care resources and services. The departments have
taken steps to create interagency councils and workgroups to facilitate
collaboration and sharing of information, establish working
relationships among their leaders, and develop communication channels
to further health care resource sharing. In addition, the departments
developed a Joint Strategic Plan outlining six goals. However, JEC and
HEC have not seized upon a number of opportunities to further
collaboration and coordination. For example, JEC and HEC have not
developed a system for collecting and monitoring information on the
health care services that each department contracts for from the
private sector”such as individual VA medical center or military
treatment facility contracts for dialysis, laboratory services, or
magnetic resonance imaging. If such a system were in place, the
departments could use it to identify services that could be exchanged
from one another or possibly obtain better contract pricing through
joint purchasing of services, thus promoting systemwide cost savings
and efficiencies. Furthermore, JEC and HEC have not directed that a
joint nationwide market analysis be conducted to obtain information on
what their combined future workloads will be in the areas of services,
facilities, and patient needs.
VA and DOD lack performance measures that would be useful for
evaluating how well they are achieving their health care resource-
sharing goals. For example, of the 30 measures contained in the
departments‘ joint strategic plan, 5 were not developed at the time the
plan was issued and 11 lacked longitudinal information. For the
remaining 14 that require periodic measurement, there was variation in
the rigor or specificity in the types of data to be collected or the
analysis to be performed.
What GAO Recommends:
The Secretaries of VA and DOD should (1) develop an evaluation plan for
documenting and recording the advantages and disadvantages of each DSS
project, an activity that will assist VA and DOD in replicating
successful projects systemwide, and (2) develop performance measures
that would be useful for determining the progress of their health care
resource-sharing goals.
VA and DOD concurred with GAO‘s recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-06-315.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Laurie Ekstrand at (202)
512-7101 or ekstrandl@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Although JIF and DSS Programs Experienced Start-up Challenges, More
Than Half of the Projects Are Operational:
VA and DOD Have Taken Actions to Strengthen Health Care Resource
Sharing, but Important Opportunities Remain:
VA and DOD Lack Useful Performance Measures to Evaluate Health Care
Resource Sharing:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Joint Incentive Fund Program:
Appendix III: Demonstration Site Selection Projects for Fiscal Years
2003 through 2007:
Appendix IV: Description of VA's and DOD's Councils, Committees, and
Workgroups:
Appendix V: Comments from the Department of Veterans Affairs:
Appendix VI: Comments from the Department of Defense:
Related GAO Products:
Tables:
Table 1: JIF Program Funding:
Table 2: DSS Program Funding:
Figures:
Figure 1: JIF Program Implementation Timeline:
Figure 2: DSS Program Implementation Timeline:
Figure 3: VA/DOD JEC Organizational Chart, as of October 2005:
Abbreviations:
BEC: Benefits Executive Council:
BHIE: Bidirectional Health Information Exchange:
BRAC: base realignment and closure:
CARES: Capital Asset Realignment for Enhanced Services:
CCQAS: Centralized Credentials Quality Assurance System:
CHCSI: Composite Health Care System I:
CHCSII: Composite Health Care System II (renamed the Armed Forces
Health Longitudinal Technology Application in November 2005):
CMAC: Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS) Maximum Allowable Charge:
CPC: VA/DOD Construction Planning Committee:
DOD: Department of Defense:
DSS: Demonstration Site Selection:
GME: graduate medical education:
GPRA: Government Performance and Results Act of 1993:
HEC: Health Executive Council:
JEC: Joint Executive Council:
JIF: Joint Incentive Fund:
LDSI: Laboratory Data Sharing Initiative:
MRI: magnetic resonance imaging:
MTF: military treatment facility:
NDAA: National Defense Authorization Act for Fiscal Year 2003:
OMB: Office of Management and Budget:
PMA: President's Management Agenda:
VA: Department of Veterans Affairs:
VAMC: VA medical center:
VISTA: Veterans Health Information Systems and Technology Architecture:
United States Government Accountability Office:
Washington, DC 20548:
March 20, 2006:
Congressional Committees:
Combined, the Department of Veterans Affairs (VA) and Department of
Defense (DOD) provided health care services to about 13.5 million
beneficiaries in fiscal year 2004 at a cost of about $57 billion--$26.8
billion for VA and $30.4 billion for DOD.[Footnote 1] For decades the
Congress has encouraged VA and DOD to increase their resource-sharing
activities to achieve the most cost-effective use of health care
resources and deliver health care services more efficiently. Further,
the President's Management Agenda (PMA) contains an initiative that
specifically focuses on improving coordination of VA and DOD programs
and systems by increasing the sharing of services that will lead to
reduced cost and increased quality of care.
The Congress included in the National Defense Authorization Act for
Fiscal Year 2003 (NDAA) a provision that VA and DOD implement two
programs--the joint incentive program[Footnote 2] and the demonstration
program[Footnote 3]--to increase the amount of health care resource
sharing taking place between VA and DOD. In addition, the act required
that we report on VA and DOD's progress in implementing the programs
and, as agreed with the committees of jurisdiction, the extent projects
funded under the programs are operational.[Footnote 4] Further, the
committees of jurisdiction asked us to describe the actions taken by VA
and DOD to strengthen the sharing of health care resources between the
two departments and opportunities to improve upon these actions as well
as to assess whether VA and DOD performance measures are useful for
evaluating progress toward achieving health care resource-sharing
goals.
To assess VA's and DOD's progress in implementing the Joint Incentive
Fund (JIF) and Demonstration Site Selection (DSS) programs, we
conducted site visits at six project sites and interviewed department
officials responsible for the development of each of the
projects.[Footnote 5] In addition, we contacted VA and DOD officials
from seven additional sites.[Footnote 6] For all of the sites, we
reviewed project documentation for JIF projects selected in fiscal year
2004 and DSS projects that consisted of a detailed description of the
project, a timeline for development and implementation, associated
risks, costs, potential cost savings (if applicable), staffing
requirements, and quarterly progress reports for each project.[Footnote
7]
To obtain information on the actions taken by VA and DOD to strengthen
the sharing of health care resources, we spoke with officials from VA's
Office of Policy, Planning, and Preparedness and the Veterans Health
Administration--including the VA/DOD Liaison Office and VA medical
center (VAMC) staff at several locations engaged in the sharing of
health care resources. We interviewed officials from DOD's TRICARE
Management Activity;[Footnote 8] the DOD/VA Program Coordination
Office; the military services' surgeons general offices, which
coordinate sharing activities; and several military treatment
facilities (MTF) engaged in the sharing of health care resources. We
also interviewed officials from Joint Executive Council (JEC)
committees and Health Executive Council (HEC) workgroups[Footnote 9] to
determine what policies, procedures, and guidance have been promulgated
to promote health care resource sharing and coordination between VA and
DOD. Further, we spoke with officials from the Office of Management and
Budget (OMB). We analyzed the charters and briefing updates for each
JEC committee and HEC workgroup and reviewed OMB's evaluation of the
departments' efforts to implement the PMA initiative. In addition, we
analyzed workload, cost, and sharing agreement data between VA and each
branch of military service.
To assess whether VA and DOD performance measures are useful, we
interviewed senior VA and DOD officials about how the sharing of health
care resources is measured. In addition, we analyzed the departments'
Joint Strategic Plan for Fiscal Year 2005, the departments' JEC annual
report to the Congress on sharing, and each department's individual
strategic plan. We also obtained and reviewed VA and DOD policies
governing sharing and reviewed relevant department reports, including
those from the DOD Inspector General and DOD contractors, along with
our prior work. We performed our work from January 2005 through March
2006 in accordance with generally accepted government auditing
standards. For more details on our scope and methodology, see appendix
I.
Results in Brief:
VA and DOD are making progress in implementing two programs required by
the Congress in December 2002 to encourage health care resource sharing
and collaboration between VA and DOD--JIF and DSS. While JIF projects
experienced challenges because of delays resulting from the initial
absence of funding mechanisms and, in some cases, the need for
additional acquisition and construction approvals, as of December 2005,
7 of 11[Footnote 10] selected 2004 projects were operational. The DSS
program also experienced challenges as some sites reported difficulty
putting together project submission packages, noting confusion over the
timelines and approval process as well as frustration with the amount
of paperwork and rework required. Nonetheless, as of December 2005, 7
of the 8 DSS projects were operational.[Footnote 11] However, JEC and
HEC have not established a plan to measure and evaluate the advantages
and disadvantages of DSS projects--information that will be useful for
determining whether projects that produce cost savings or enhance
health care delivery efficiencies can be replicated systemwide.
VA and DOD are creating mechanisms that support the potential to
increase collaboration, sharing, and coordination of management and
oversight of health care resources and services. The departments have
taken steps to create interagency councils and workgroups to facilitate
the sharing and collaboration of information, establish working
relationships among their leaders, and develop communication channels
to further health care resource sharing. In addition, the departments
have worked together to develop a Joint Strategic Plan outlining six
goals. However, JEC and HEC have not seized upon a number of
opportunities to further health care resource sharing, collaboration,
and coordination. For example, JEC and HEC have not developed a system
for collecting, tracking, and monitoring information on the health care
services that each department contracts for from the private sector.
Such a system could promote systemwide cost savings and efficiencies as
the departments could exchange services from one another or possibly
obtain better contract pricing through joint purchasing of services. In
one case in northern California, VA and the Air Force were
independently contracting with private providers for dialysis services-
-information that is not stored in a database to be shared with all VA
and DOD health care facilities. During discussions with each other,
local VA and Air Force officials recognized they were paying a high
cost for dialysis services, got together to analyze their costs and
determine the best approach for obtaining these services, and worked
together to open a joint dialysis clinic. In this case, had VA and the
Air Force known about their individual contracting arrangements, they
could have combined their contracting needs and negotiated services at
a lower cost or opened a joint clinic earlier. Furthermore, JEC and HEC
have not directed that a joint nationwide market analysis be conducted
to obtain information on what their combined future workloads will be
in the areas of services, facilities, and patient needs.
VA and DOD lack performance measures that would be useful for
evaluating how well the departments are achieving their health care
resource-sharing goals. For example, of the 30 measures contained in
the departments' joint strategic plan, 5 that were called for in the
plan were not developed at the time the plan was issued and 11 lacked
long-term or longitudinal information. For the remaining 14 that
require periodic measurement, there was variation in the rigor or
specificity in the types of data to be collected or the analysis to be
performed.
We are recommending that the Secretaries of Veterans Affairs and
Defense direct JEC and HEC to take two actions to advance health care
resource-sharing activities between the departments. In commenting on a
draft of this report, VA and DOD concurred with our recommendations.
Background:
VA operates one of the nation's largest health care systems. In fiscal
year 2004, VA provided health care to approximately 5.2 million
veterans at 157 VAMCs and almost 900 outpatient clinics
nationwide.[Footnote 12] In fiscal year 2004, DOD provided health care
to approximately 8.3 million beneficiaries,[Footnote 13] including
active duty personnel and retirees, and their dependents. DOD health
care is provided at more than 530 Army, Navy, and Air Force MTFs
worldwide and is supplemented by TRICARE's network of civilian
providers. Through its TRICARE contracts, DOD uses civilian managed
health care support contractors to develop networks of primary and
specialty care providers and to provide other customer service
functions, such as claims processing. DOD's policy encourages inclusion
of all VA health care facilities in its networks.
Health care expenditures for VA and DOD are increasing. VA's
expenditures have grown--from about $12 billion in fiscal year
1990[Footnote 14] to about $26.8 billion in fiscal year 2004--as an
increasing number of veterans look to VA to meet their health care
needs. DOD's health care spending has gone from about $12 billion in
fiscal year 1990[Footnote 15] to about $30.4 billion in fiscal year
2004--in part, to meet additional demand resulting from congressional
actions to expand program eligibility for military retirees,
reservists, members of the National Guard, and their dependents, along
with the increased needs of active duty personnel involved in conflicts
in Afghanistan (Operation Enduring Freedom) and in Iraq (Operation
Iraqi Freedom). Today, VA and DOD officials are reporting that many of
their facilities are at capacity or exceeding capacity. The nature of
sharing has shifted from one of utilizing untapped resources to one of
partnering and gaining efficiencies by leveraging resources or buying
power jointly. For example, VA and DOD have achieved efficiencies and
cost avoidance through a concerted effort to jointly procure
pharmaceuticals.[Footnote 16]
Congressional Initiatives to Increase Health Care Resource Sharing:
The Congress has had a long-standing interest in expanding VA and DOD
health care resource sharing. In 1982, the Congress passed the
Veterans' Administration and Department of Defense Health Resources
Sharing and Emergency Operations Act (Sharing Act).[Footnote 17] The
act authorizes VA and DOD to enter into sharing agreements to buy,
sell, and barter health care resources to better utilize excess
capacity. The head of each VA and DOD medical facility can enter into
local sharing agreements. However, VA and DOD headquarters officials
review and approve agreements that involve national commitments, such
as joint purchasing of pharmaceuticals. VA and DOD sharing activities
have typically fallen into three categories.
* Local sharing agreements allow VA and DOD to take advantage of their
facilities' capacity to provide health care by being providers of
health services, receivers of health services, or both. Health services
shared under these agreements can include inpatient and outpatient
care; ancillary services, such as diagnostic and therapeutic radiology;
dental care; and specialty care services, such as treatment for spinal
cord injuries. Other examples of services shared under these agreements
include support services, such as administration and management;
research; education and training; patient transportation; and laundry.
The goals of local sharing agreements are to allow VAMCs and MTFs to
capitalize on their combined purchasing power, exchange health services
to maximize use of resources, and provide beneficiaries with greater
access to care.
* Joint venture sharing agreements, as distinguished from local sharing
agreements, aim to avoid costs by pooling resources to build a new
facility or jointly use an existing facility. Joint ventures require an
integrated approach, as two separate health care systems must develop
multiple sharing agreements that allow them to operate as one system at
one location.
* National sharing initiatives are designed to achieve greater
efficiencies, that is, to lower cost and improve access to goods and
services when they are acquired on a national level rather than by
individual facilities--for example, VA and DOD's efforts to jointly
purchase pharmaceuticals and surgical instruments for nationwide
distribution.
Later, in January 2002, the Congress passed legislation requiring VA
and DOD to conduct a comprehensive assessment that would identify and
evaluate changes to their health care delivery policies, methods,
practices, and procedures in order to provide improved health care
services at reduced cost to the taxpayer.[Footnote 18] To facilitate
this, VA and DOD hired a contractor (at a cost of $2.5 million) to
conduct the Joint Assessment Study that was completed on December 31,
2003.[Footnote 19] Unlike previous studies conducted by VA and DOD, the
Joint Assessment Study combined VA and DOD beneficiary populations into
a single market by geographic site.[Footnote 20] The contractor
examined collaboration and sharing opportunities in three VA and DOD
market areas: Hawaii; the Gulf Coast (Mississippi to Florida); and
Puget Sound, Washington. Specifically, the study included a detailed
independent review of options to colocate or share facilities and care
providers in areas where duplication and some excess capacity may
exist; optimize economies of scale through joint procurement of
supplies and services; and partially or fully integrate VA and DOD
systems to provide tele-health services, provider credentialing,
cardiac surgical programs, rehabilitation services, and administrative
services.
The NDAA, passed in December 2002, required that VA and DOD implement
two programs--JIF and DSS--to increase the amount of health care
resource sharing taking place between VA and DOD. Under JIF, the
departments are to identify and provide incentives to implement, fund,
and evaluate creative health care coordination and sharing initiatives.
Under DSS, the departments are to select projects to serve as a test
for evaluating the feasibility, advantages, and disadvantages of
programs designed to improve the sharing and coordination of health
care resources. The NDAA also required VA and DOD jointly to develop
and implement guidelines for a standardized, uniform payment and
reimbursement schedule for selected health care services. In response,
the departments established a standardized reimbursement methodology
effective October 2003, between VA and DOD medical facilities through a
memorandum of agreement implementing standardized outpatient billing
rates based on the discounted Civilian Health and Medical Program of
the Uniformed Services (CHAMPUS) Maximum Allowable Charges
(CMAC)[Footnote 21] schedule.
Guidance Related to Strategic Planning and Performance Measures:
The NDAA also required VA and DOD to develop and publish a joint
strategic plan to shape, focus, and prioritize the coordination and
sharing efforts within the departments and incorporate the goals and
requirements of the joint strategic plan into the strategic plan of
each department.[Footnote 22] We have reported that there is no more
important element in results-oriented management than an agency's
strategic planning effort.[Footnote 23] This is the starting point and
foundation for defining what the department seeks to accomplish,
identifying the strategies it will use to achieve desired results, and
then determining how well it succeeds in reaching goals and achieving
objectives. We also previously reported that traditional management
practices involve the creation of long-term strategic plans and regular
assessments of progress toward achieving the plans' stated
goals.[Footnote 24]
Moreover, the Government Performance and Results Act of 1993 (GPRA)
requires agencies to set goals, measure performance, and report on
their accomplishments.[Footnote 25] Performance measures are a key tool
to help managers assess progress toward achieving the goals or
objectives stated in their plans. They are also an important
accountability tool to communicate department progress to the Congress
and the public.
Program performance measurement is commonly defined as the regular
collection and reporting of a range of data, including a program's:
* inputs, such as dollars, staff, and materials;
* workload or activity levels, such as the number of applications that
are in process, usage rates, or inventory levels;
* outputs or final products, such as the number of children vaccinated,
number of tax returns processed, or miles of road built;
* outcomes of products or services, such as the number of cases of
childhood illnesses prevented or the percentage of taxes collected;
and:
* efficiency, such as productivity measures or measures of the unit
costs for producing a service.
Other data might include information on customer satisfaction, program
timeliness, and service quality. Managers can use the data that
performance measures provide to help them manage in three basic ways:
to account for past activities, to manage current operations, or to
assess progress toward achieving planned goals and objectives. When
used to look at past activities, performance measures can show the
accountability of processes and procedures used to complete a task, as
well as program results. When used to manage current operations,
performance measures can show how efficiently resources, such as
dollars and staff, are being used. Finally, when tied to planned goals
and objectives, performance measures can be used to assess how
effectively a department is achieving the goals and objectives stated
in its long-range strategic plan.
OMB, through the PMA released in the summer of 2001, has emphasized
improving government performance through governmentwide and agency-
specific initiatives. OMB is responsible for overseeing the
implementation of the PMA and tracking its progress. According to OMB's
mission statement, its role is to help improve administrative
management, develop better performance measures and coordinating
mechanisms, and reduce any unnecessary burdens on the public. For each
initiative, OMB has established "standards for success" and rates
agencies' progress toward meeting these standards. Among the PMA
initiatives, one specifically focuses on improving coordination of VA
and DOD programs and systems by increasing the sharing of services that
will lead to reduced cost and increased quality of care.
Although JIF and DSS Programs Experienced Start-up Challenges, More
Than Half of the Projects Are Operational:
While JIF projects experienced challenges caused by delays resulting
from the initial absence of funding mechanisms and, in some cases, the
need for additional acquisition and construction approvals, as of
December 2005, 7 of 11[Footnote 26] selected 2004 projects were
operational. DSS also experienced challenges as some sites reported
difficulty putting together project submission packages, noting
confusion over the timelines and approval process as well as
frustration with the amount of paperwork and rework required.
Nonetheless, as of December 2005, 7 of the 8 DSS projects were
operational.
JIF Projects Slowly Becoming Operational:
The JIF program is to identify, fund, and evaluate creative health care
coordination and sharing initiatives. Under the program, VA and DOD
solicit proposals from their program offices, VAMCs, or MTFs for
project initiatives at least annually. Legislation requires that the
Secretaries of VA and DOD each contribute a minimum of $15 million from
each department's appropriation into a no-year[Footnote 27] account
established in the U.S. Treasury for each of fiscal years 2004 through
2007. From December 2002 through May 2005, VA and DOD developed JIF
program guidelines, solicited and reviewed proposals, established an
account within the U.S. Treasury for funding projects, and selected and
funded projects. A memorandum of agreement entered into by VA and DOD
assigned the Financial Management Workgroup--a group established by
HEC--as the administrator of JIF. The Financial Management Workgroup
has oversight responsibility for the implementation, monitoring, and
evaluation of the JIF program. The members of the workgroup review
concept proposals for selection and provide their recommendations to
HEC for final approval. They developed the following criteria[Footnote
28] to be used for evaluating the concept proposals and selecting the
final projects:
* support DOD and VA's joint long-term approach to meeting the health
care needs of their beneficiary populations;
* improve beneficiary access;
* ensure exportability to other facilities;
* maximize the number of beneficiaries who would benefit from the
initiative;
* result in cost savings or cost avoidance;
* develop in-house capability at a lesser cost for services now
obtained by contract; and:
* demonstrate that the project would be self-sustaining within 2 years.
If funding is needed beyond 2 years, the local facility, the Surgeon
General's office, or the Veterans Integrated Service Network[Footnote
29] must agree to provide it.
VA and DOD officials completed their review of 58 concept proposals
that were submitted for the fiscal year 2004 funding cycle and
ultimately selected 12 projects (subsequently reduced to 11) for
funding in November 2004. VA and DOD issued a request for project
proposals for the fiscal year 2005 funding cycle in November 2004.
Submissions were due by January 2005, and according to VA and DOD
officials, 56 concept proposals were submitted. VA and DOD reviewed the
concept proposals in September 2005 and selected 18 for funding
(subsequently reduced to 17).[Footnote 30] See figure 1 for a timeline
and associated events affecting the implementation of the JIF program.
Figure 1: JIF Program Implementation Timeline:
[See PDF for image]
[A] Originally 12 projects were selected; however, 1 project was
removed due to legal concerns.
[B] Originally 18 projects were selected; however, 1 project was
removed due to asset realignment issues.
[End of figure]
Beginning in fiscal year 2004, each department as required by law,
began contributing $15 million annually into the U.S. Treasury account
established for funding JIF.[Footnote 31] VA and DOD report that as of
January 2006, $54.3 million of the $90 million they contributed has
been allocated to specific projects, and $5.3 million has been
obligated. (See table 1.) For the 2004 JIF projects, project selection
took place in August 2004. Initial funding for some of the projects
began in November 2004. However, it was not until May 2005--about 2½
years after the program was established--that initial funding was
provided to the last of the approved projects.
Table 1: JIF Program Funding:
Fiscal year: 2004;
Department required contributions: $30;
Allocated[A]: $0;
Obligated[B]: $0.
Fiscal year: 2005;
Department required contributions: $30;
Allocated[A]: $15.3;
Obligated[B]: $5.3.
Fiscal year: 2006;
Department required contributions: $30;
Allocated[A]: $39.0[C];
Obligated[B]: -.
Fiscal year: 2007 (projected);
Department required contributions: $30;
Allocated[A]: -;
Obligated[B]: -.
Fiscal year: Total;
Department required contributions: $120;
Allocated[A]: $54.3;
Obligated[B]: $5.3.
Sources: VA and DOD.
[A] For the purposes of this report, allocated represents the amount of
money designated for specific projects.
[B] For the purposes of this report, obligated represents the amount of
allocated funds that have been committed to project activities.
[C] Of the $39.0 million, $7.7 million was allocated toward year 2
funding for 2004 projects and the remaining $31.3 million was allocated
for 2005 projects.
[End of table]
According to officials from both departments, funding delays occurred
for a number of reasons. VA and DOD needed time to set up the U.S.
Treasury account and to establish funding mechanisms to facilitate the
transfer of funds from the account to individual VAMCs or MTFs.
Further, funding could not be provided until project officials and the
surgeons general for DOD's Departments of the Army, Navy, and Air Force
completed required administrative actions. These actions included
obtaining assurance from the surgeons general that service-specific
department protocols for disbursing funds were followed and obtaining
certification from project officials that projects would be self-
sustaining within 2 years.
While all approved fiscal year 2004 projects have now received funding,
those still in the development phase are in the process of acquiring
needed equipment, staff, or space. In addition to the delays caused by
VA and DOD administrative processes to fund projects, the individual
projects experienced delays for other reasons. For example, officials
from both departments reported that additional approvals for
acquisition of equipment and minor construction were needed before some
projects could be initiated. Specifically, VA and DOD officials in
North Chicago, Illinois, stated that in addition to the approvals
required from HEC's Financial Management Workgroup and the Navy Surgeon
General's Office, they were also required to seek and obtain
acquisition approval from the National Acquisition Center for the
mammography unit requested in their project. The officials stated that
these three distinct approval processes for their JIF project should
have been merged into a single approval process. Further, VA and DOD
officials in Honolulu, Hawaii, reported that because of delays in
obtaining acquisition approvals, pricing increases occurred, resulting
in increased cost to the government. Initial project approval occurred
in August 2004; however, final contract approval was not granted as of
December 2005, over a year later.[Footnote 32]
As of December 2005, 4 of the 11 JIF fiscal year 2004 projects were
still in the development stage, with 7 of 11 operational. Some of the
projects that were operational include a joint dialysis unit located at
Travis Air Force Base, Fairfield, California, that according to VA and
DOD officials, improves access for VA and DOD beneficiaries and lessens
the cost to the government by reducing purchased services from the
private sector; a tele-radiology unit located at the VAMC in Spokane,
Washington, that is providing tomography scans for DOD beneficiaries;
and an imaging services unit at Elmendorf Air Force Base in Anchorage,
Alaska, that allows VA and DOD to pool their imaging needs and provide
services in-house instead of contracting for them at very expensive
fees charged by providers in this remote area. See appendix II for
details about JIF projects selected in fiscal years 2004 and 2005.
Most Demonstration Site Projects Are Operational:
DSS projects are piloting different approaches to sharing health care
resources in three areas--budget and financial management, coordinated
staffing and assignment, and medical information and information
technology. Further, each DSS project contains individual goals that
have the potential to promote VA and DOD health care resource sharing
and collaboration. The objective of each project is aligned with VA's
and DOD's strategic goal to jointly acquire, deliver, and improve
health care services. From July 2003 through August 2004, VA and DOD
developed DSS program guidelines, solicited and reviewed proposals, and
began funding projects. Eight projects were approved by HEC in October
2003; project funding began in August 2004; and as of December 2005,
seven projects were operational.
The DSS program is to serve as a test for evaluating the feasibility
and the advantages and disadvantages of projects designed to improve
sharing. The Joint Facility and Utilization Workgroup--a group
established by HEC--is responsible for DSS project selection and
oversight. Projects selected by the workgroup must be approved by HEC.
As required by the statute, there must be a minimum of three VA and DOD
demonstration sites (projects) selected. Also, at least one project was
required to be tested in each area.
As required by law, each department was required to make available at
least $3 million in fiscal year 2003, at least $6 million in fiscal
year 2004, and at least $9 million for each subsequent year in fiscal
years 2005 through 2007 to fund DSS projects.[Footnote 33] During
fiscal year 2003 no funds were allocated or obligated to projects
because, according to VA and DOD officials, the business plans for the
sites had not been finalized. During fiscal years 2004 and 2005,
approximately $6.2 million and $12.7 million, respectively, of the $36
million made available by VA and DOD, were allocated to specific DSS
projects, and $14.4 million was obligated. See table 2 for the amount
of funds made available, allocated, and obligated for the DSS program.
Table 2: DSS Program Funding:
Fiscal year: 2003;
Funds made available by VA and DOD: $6;
Allocated[A]: $0[C];
Obligated[B]: $0.
Fiscal year: 2004;
Funds made available by VA and DOD: 12;
Allocated[A]: $6.2;
Obligated[B]: $4.9.
Fiscal year: 2005;
Funds made available by VA and DOD: 18;
Allocated[A]: $12.7;
Obligated[B]: $9.5.
Fiscal year: 2006 (projected);
Funds made available by VA and DOD: 18;
Allocated[A]: $10.2;
Obligated[B]: -.
Fiscal year: 2007 (projected);
Funds made available by VA and DOD: 18;
Allocated[A]: $9.7;
Obligated[B]: -.
Fiscal year: Total;
Funds made available by VA and DOD: $72;
Allocated[A]: $38.8;
Obligated[B]: $14.4.
Sources: VA and DOD.
[A] For the purposes of this report, allocated represents the amount of
money designated for specific projects.
[B] For the purposes of this report, obligated represents the amount of
allocated funds that have been committed to project activities.
[C] According to VA and DOD officials, funding was not allocated in
2003 because the business plans for the sites had not been finalized.
[End of table]
From July 2003 through October 2003, VA and DOD developed program
guidelines and solicited and reviewed project proposals. Each proposal
was reviewed and scored by members of the Joint Facility and
Utilization Workgroup for each category for which it had been
submitted. For example, according to VA and DOD officials, under budget
and financial management, one of the criteria for selection included
whether a project allowed managers to assess the advantages and
disadvantages--in terms of relative costs, benefits, and opportunities-
-of using resources from either department to provide or enhance the
delivery of health care services to beneficiaries of either department.
For coordinated staffing and assignment projects, criteria included
whether the project could demonstrate agreement on staffing
responsibilities in providing joint services and the development of a
plan to provide adequate staffing in the event of deployment or
contingency operation. Criteria related to medical information and
information technology included whether a project could communicate
medical information and incorporate minimum standards of information
quality and information assurance related to either credentialing,
consolidated mail outpatient pharmacy, or laboratory data sharing.
According to VA and DOD officials, upon selection DSS projects are to
be monitored via periodic progress assessments to ensure that project
activities align with the cost, schedule, and performance parameters
outlined in the submitted business plan.
The Joint Facility and Utilization Workgroup forwarded eight DSS
project proposals to HEC, which approved them in October 2003. However,
sites reported some difficulty putting together the project submission
packages. For example, one site noted there was initial confusion over
the timelines and approval process as each department had differing
requirements. Another site expressed frustration with the amount of
paperwork and rework required. Nevertheless, by June 2004 the sites
developed and submitted for VA and DOD approval proposed implementation
and business plans for their projects, in August 2004 VA and DOD began
project funding, and in May 2005 VA and DOD reported that they had
approved all the proposed project business plans. As of December 2005,
VA and DOD reported that the following seven DSS projects were
operational:
* A project at San Antonio, referred to as the Laboratory Data Sharing
Initiative (LDSI), has been successful in enabling each department to
conduct laboratory tests and share the results with each other. This
project allows a VA provider to electronically order laboratory tests
and receive results from a DOD facility, and conversely, a DOD provider
can electronically order laboratory tests and receive results from a VA
facility. An early version of what is now LDSI was originally tested
and implemented at a joint VA and DOD medical facility in Hawaii in May
2003. The San Antonio LDSI demonstration project built on the Hawaii
version and enhanced it. According to the departments, a plan to export
LDSI to additional sites has been approved.
* An electronic data exchange project at El Paso successfully exchanged
laboratory orders and results as well as limited patient information--
demographic, outpatient pharmacy, radiology, laboratory, and allergy
data.
* An electronic data exchange project at Puget Sound has also achieved
similar results by exchanging limited patient information--
demographic, outpatient pharmacy, radiology, allergy data, and
discharge summaries. The results of the project are scheduled to be
replicated at five additional VA and DOD sites during the first quarter
of fiscal year 2006.
* A project at Augusta to coordinate the staffing and sharing of nurses
at VA and DOD facilities has yielded savings in terms of cost, time,
and training resources.
* A project in Alaska is producing itemized bills for each individual
VA patient seen at the DOD facility. The cost for each patient visit is
then credited in VA's accounting system to capture the workload.
* A project at San Antonio has successfully shared credentialing data
for licensed VA and DOD providers through an interface between the two
departments' individual credentialing systems.
* A project at Hampton is using an automated tool to evaluate staffing
shortfalls and mitigate identified gaps in the resources needed to
provide health care services to VA and DOD beneficiaries.
According to VA and DOD officials, they plan to evaluate whether the
eight projects were successful and if they can be replicated at other
VA and DOD medical facilities. However, as of November 2005, VA and DOD
had not developed an evaluation plan for making these assessments. See
appendix III for additional details about the DSS projects. See figure
2 for a timeline and associated events affecting the implementation of
the DSS program.
Figure 2: DSS Program Implementation Timeline:
[See PDF for image]
[End of figure]
VA and DOD Have Taken Actions to Strengthen Health Care Resource
Sharing, but Important Opportunities Remain:
VA and DOD have taken steps to create interagency councils and
workgroups to facilitate the sharing and collaboration of information,
establish working relationships among their leaders, and develop
communication channels to further health care resource sharing.
However, JEC and HEC have not seized upon a number of opportunities to
further collaboration and coordination.
Actions Taken to Enhance Health Care Resource Sharing:
In addition to the development of congressionally mandated JIF and DSS
programs, VA and DOD have created mechanisms to enhance health care
resource sharing by forming JEC and through a proposed federal health
care facility in North Chicago. The two departments have also worked
together to develop a Joint Strategic Plan outlining six goals.
Joint Executive Council:
In February 2002, VA and DOD established JEC to enhance VA and DOD
collaboration; ensure the efficient use of federal services and
resources; remove barriers and address challenges that impede
collaborative efforts; assert and support mutually beneficial
opportunities to improve business practices; facilitate opportunities
to enhance sharing arrangements that ensure high-quality, cost-
effective services for both VA and DOD beneficiaries; and develop a
joint strategic planning process to guide the direction of joint
sharing activities.[Footnote 34] JEC is co-chaired by the Deputy
Secretary of Veterans Affairs and the Under Secretary of Defense for
Personnel and Readiness.[Footnote 35] Membership consists of senior
leaders from both VA and DOD, including VA's Under Secretary for
Benefits and Under Secretary for Health and DOD's Principal Deputy
Under Secretary of Defense for Personnel and Readiness and Assistant
Secretary for Health Affairs. JEC established two interagency councils
and two interagency committees to facilitate collaboration: (1)
Benefits Executive Council, (2) HEC, (3) VA/DOD Construction Planning
Committee (CPC), and (4) Joint Strategic Planning Committee.
HEC was placed under the purview of JEC specifically to advance VA and
DOD health care resource sharing and collaboration. Through HEC, VA and
DOD have developed policies and procedures for facilitating health care
resource-sharing activities. Together, the two departments are working
to create, implement, and adhere to joint standards in the areas of
clinical guidelines, information technology, deployment health
policies, and purchasing of medical and surgical supplies. HEC has
organized itself into 11 workgroups--on subjects such as financial
management, pharmacy, and deployment health--in order to carry out its
mission (see fig. 3).[Footnote 36] HEC's mission includes formulating
VA and DOD joint policies that relate to health care, facilitating the
exchange of patient information, and ensuring patient safety. HEC
membership includes senior leaders from VA and DOD. HEC is co-chaired
by VA's Under Secretary for Health and DOD's Assistant Secretary of
Defense for Health Affairs. DOD membership also includes the surgeons
general for the military services. See appendix IV for a description of
VA's and DOD's councils, committees, and workgroups.
Figure 3: VA/DOD JEC Organizational Chart, as of October 2005:
[See PDF for image]
[End of figure]
HEC workgroups, such as Joint Facility Utilization/Resource Sharing,
Deployment Health, and Evidence-Based Practice Guidelines, develop and
implement changes in policy and guidance approved by HEC. For example,
the Deployment Health Workgroup has developed medical and public health
policy for active duty service members who have been exposed to
tuberculosis, to be treated by VA without co-payment. This policy
allows separating service members to continue to receive
antituberculosis prophylactic treatment at a VA facility following
their separation from active duty military service. Further, the
Deployment Health Workgroup has developed a roster identifying
Operation Enduring Freedom and Operation Iraqi Freedom veterans who are
separating or who have separated from active duty military service. VA
is using this roster to mail letters to individuals thanking them for
their service and advising them of their VA benefits based on their
service in a combat theater. VA is also using this roster to determine
postdeployment VA health care utilization by this population of
veterans. Other efforts include the Evidence-Based Practice Guidelines
Workgroup's development of standardized guidelines to improve patient
outcomes for both VA and DOD beneficiaries. In fiscal year 2005, the
workgroup began revising four of its guidelines, including
rehabilitation for servicemembers with amputations. Completed
guidelines are presented at various national meetings. Tools such as CD-
ROMs, pocket cards, and patient brochures are made available for VA and
DOD providers in order to enhance communications with their patients.
North Chicago Federal Health Care Facility:
JEC and HEC are also promoting integration through the establishment of
a combined VA and DOD federal health care facility in North Chicago.
According to VA and DOD, it was through discussions during JEC and HEC
meetings that the combined federal facility in North Chicago was
envisioned. According to a DOD official, the combined facility will be
a hospital. The current plan is to build an ambulatory care clinic that
will be attached to the current VA medical center. According to the DOD
official, for the first time VA and DOD will operate a facility under a
single chain of command that would integrate the budget and management
for providing medical services from both departments to achieve one
cohesive medical facility that serves VA and DOD beneficiaries. This
management structure differs significantly from joint ventures in which
separate VA and DOD management structures coexist. The North Chicago
Federal Health Care Facility is scheduled to be operational in fiscal
year 2010.
Joint Strategic Plan:
VA and DOD also developed a strategic plan in December 2004 that
includes six joint goals.[Footnote 37] Each of JEC's councils and
committees and HEC's workgroups has been assigned responsibility for
meeting some aspects of the goals outlined in the joint strategic plan.
For example, according to VA and DOD officials, the Financial
Management Workgroup developed a standardized business case analysis
template for the JIF program to increase efficiency of operations. VA
and DOD staff utilize this template when requesting funding for joint
projects. Previously, the individual branches of the service had their
own templates, all of which were slightly different. The departments'
joint goals are as follows:
* Goal 1: Leadership Commitment and Accountability. Promote
accountability, commitment, performance measurement, and enhanced
internal and external communication through a joint leadership
framework.
* Goal 2: High-Quality Health Care. Improve the access, quality,
effectiveness, and efficiency of health care for beneficiaries through
collaborative activities.
* Goal 3: Seamless Coordination of Benefits. Promote coordination of
benefits to improve understanding of and access to benefits and
services earned by servicemembers and veterans through each stage of
life, with a special focus on ensuring a smooth transition from active
duty to veteran status.
* Goal 4: Integrated Information Sharing. Ensure that appropriate
beneficiary and medical data are visible, accessible, and
understandable through secure and interoperable information management
systems.
* Goal 5: Efficiency of Operations. Improve management of capital
assets, procurement, logistics, financial transactions, and human
resources.
* Goal 6: Joint Medical Contingency/Readiness Capabilities. Ensure the
active participation of both departments in federal and local incident
and consequence response through joint contingency planning, training,
and exercising.
Opportunities to Strengthen Health Care Resource Sharing Remain:
While progress has been made, JEC and HEC--which are responsible for
advancing VA and DOD health care resource sharing and collaboration--
have not seized upon a number of opportunities to promote sharing and
collaboration. For example, during the course of our audit work, we
found that JEC and HEC have not developed a system for jointly
collecting, tracking, and monitoring information on the health care
services that VA and DOD contract for from the private sector; directed
that a joint nationwide market analysis be conducted that contains
information on what the departments' combined future workloads will be
in the areas of services, facilities, and patient needs; disseminated
in a timely manner the information or the tools developed by a
congressionally required study (the Joint Assessment Study) for
assessing collaboration and sharing opportunities; or established
standardized inpatient reimbursement rates--initiatives that would be
useful for maximizing health care resource-sharing opportunities and
promoting systemwide cost savings and efficiencies.
System for Tracking VA and DOD Purchased Services:
Though the Army, Air Force, and Navy each record the amount of care
that is purchased from the private sector, they do not collectively
merge that information or combine it with VA's total expenditures for
services purchased from the community. As a result, a systematic
approach for collecting, tracking, and monitoring information on the
services that each department contracts for from the private sector is
lacking.
Such an approach could help VA and DOD achieve systemwide cost savings
and efficiencies, as has been demonstrated at the local level where
officials at certain sites compare their analyses and seek to exchange
services from one another or possibly obtain better contract pricing
through joint purchasing of services. For example, for fiscal year
2003, a VA official at one site estimated that VA reduced its cost by
$1.7 million as compared to acquiring the same services in the private
sector through its agreements with the Army; he also estimated that the
Army reduced its cost by about $1.25 million as compared to acquiring
the same services in the private sector. For instance, the site jointly
leased a magnetic resonance imaging (MRI) unit. The unit eliminated the
need for beneficiaries to travel to more distant sources of care.
According to a VA official, the purchase reduced MRI cost by 20 percent
as compared to acquiring the same services in the private sector.
The availability of such information would be helpful to VA and DOD
sites at the local level for sharing information on services they have
independently contracted for from the private sector. For example, VA
and the Air Force at a northern California site were able to create
efficiencies after recognizing that they had been independently
contracting for the same services. Both VA and the Air Force had been
sending patients to private providers for dialysis services--
information that is not stored in a database to be shared with all VA
and DOD health care facilities. During discussions, local VA and Air
Force officials recognized they were paying a high cost for dialysis
services, got together to analyze their costs and determine the best
approach for obtaining these services, and worked together to open a
joint dialysis clinic. In this case, had VA and the Air Force known
about their individual contracting arrangements, they could have
combined their contracting needs and negotiated services at a lower
cost or opened a joint clinic earlier.
Nationwide Market Analysis:
In response to our concerns and those of the Congress, VA initiated a
review of its capital assets under the Capital Asset Realignment for
Enhanced Services (CARES) program. The review was to provide a
comprehensive, long-range assessment of VA's health care system's
capital asset requirements. In May 2004, the Secretary's CARES decision
document was issued and, according to VA, serves as a road map for
aligning its facilities with the health care needs of 21st century
veterans.[Footnote 38] The CARES report addresses partnering with DOD.
It outlines existing and potential areas of sharing at the local level
and opportunities for joint ventures.
DOD was authorized to assess its infrastructure and provide base
realignment and closure (BRAC) recommendations in 2005 to an
independent commission for its review.[Footnote 39] An objective of the
2005 BRAC Commission, in addition to realigning DOD's base structure to
meet post-Cold War force structure, was to examine and implement
opportunities for greater sharing with VA. Joint cross-service groups
were tasked with analyzing common business-oriented functions, such as
health care. The Medical Joint Cross-Service Group was chartered to
review DOD's health care functions and to provide BRAC recommendations
based on that review. As we reported in July 2005, our examination of
the BRAC process found that while the medical group examined the
capacity and proximity of VA facilities to existing MTFs in its
analysis, it did not coordinate with VA to determine whether military
beneficiaries who normally receive care at MTFs could also receive care
at VA facilities in the vicinity.[Footnote 40]
Each department has individually analyzed its health care needs--in
part through VA's efforts to realign its capital assets under the CARES
process and through DOD's BRAC process. Each department issued reports,
which contained references to sharing or partnering with one another in
the future. However, JEC and HEC have not conducted a nationwide
integrated review and market analysis that would provide information on
what their combined future health care workloads and needs may be. Such
information is necessary to fully evaluate, and maximize the potential
for, health care resource-sharing opportunities. In its February 27,
2006, comments DOD stated that HEC has established a BRAC Impact and
Opportunity Ad Hoc Workgroup to explore and identify opportunities for
local collaboration and health care partnerships between VA and DOD in
areas potentially affected by BRAC action. The work of this group would
be a step in obtaining information on VA's and DOD's combined future
health care workloads and needs.
Dissemination of Results from the Joint Assessment Study:
Furthermore, JEC and HEC have not disseminated in a timely manner the
information or the tools developed by the DOD/VA Joint Assessment Study
that examined the collaboration and health care sharing opportunities
for three VA and DOD sites. For example, officials at one site stated
that they did not receive the study findings until almost a year after
it was completed. At that point, the officials stated that the market
information was outdated and of little use to the site in forecasting
and planning for future work. In addition, the study also produced a
tool for combining VA and DOD beneficiary populations by geographic
site. Utilizing this information, the contractor was able to forecast
local market demand for health services--potentially allowing VA and
DOD officials to plan and provide services to their "combined market."
Further, the contractor formulated "crosswalk" tables to assist VA and
DOD in matching similar health care services. Historically, VA and DOD
have captured health services information in varying formats and could
not always account for their workloads in the same manner. The tool
would provide VA and DOD health care managers within geographic areas
with information on the health care needs of the combined beneficiary
populations--information that could be useful to them for sharing and
joint purchase decisions. However, 2 years after development of the
tool, it is currently being utilized at one site.
Beneficiary Care:
During the course of our audit work, we also found instances in which
HEC could have asserted itself in local decision making to maximize
resource-sharing opportunities as well as to help ensure continuity of
care for beneficiaries. For example, see the following:
* In Honolulu, Hawaii, we were informed by DOD that Tripler Army
Medical Center (Tripler) had resources available to meet the health
care needs of certain VA beneficiaries, yet VA chose to send them to
its medical center in Palo Alto, California, for their care. Hawaii VA
officials told us it does this because the cost of care is borne by
Palo Alto and not by the Hawaii VA medical center, which would have to
reimburse Tripler for the care. Under this scenario, the federal
government is paying for underutilized resources and providers at
Tripler. We believe HEC has an opportunity to step in and ensure that
Tripler resources are fully maximized--an initiative that would
ultimately result in overall savings to the government. More important,
beneficiaries treated at Palo Alto return to Hawaii and require follow-
up care, and in some cases emergency care, that is often provided by
Tripler--a situation that could raise continuity of care issues. By
fully maximizing resources at Tripler, HEC would be helping to ensure
that initial treatments are provided closer to a beneficiary's home and
that continuity of care is maintained.
* In San Antonio, Texas, we found that VA contracts out approximately
$1.5 million for diagnostic services to various private sector
laboratories even though local MTFs have the capacity to provide these
services. According to VA, it contracts out to the private sector
because the costs are less than what DOD facilities charge. While it is
understandable that VA would seek to purchase services at the best
prices possible, this practice may result in greater costs to the
government as it is incurring VA's costs as well as the costs to
maintain underutilized DOD facilities. In this case, JEC and HEC have
not taken the initiative to determine the most cost-effective strategy
for meeting VA's and DOD's laboratory service needs--information that
would be useful for VA and DOD to ensure good stewardship of federal
resources.
Standardized Inpatient Reimbursement Rates:
Finally, we found that HEC could be more proactive in establishing
joint policies or guidance in a timely manner that facilitates health
care resource sharing. For example, in December 2002 legislation
required VA and DOD to establish a national standardized uniform
payment and reimbursement schedule for selected health care services.
In 2003, VA and DOD established a reimbursement rate for outpatient
services. However, VA and DOD have not yet established an inpatient
reimbursement rate. Though HEC reports it is in the process of
soliciting input and developing guidance for an inpatient rate, we
found that without an established inpatient rate local officials were
forced to negotiate rates among themselves--an activity that consumed
staff time and often created tension between partners.
OMB's Evaluation of VA and DOD Sharing Activities:
In addition to our observations on opportunities for VA and DOD to
strengthen health care resource sharing, OMB, the agency responsible
for improving administrative management in the executive branch, also
sees room for improvement in achieving the President's goal to increase
VA and DOD health care resource-sharing activities. OMB evaluates VA
and DOD's health care resource-sharing activities by providing an
overall or composite score on their ability and progress to:
* exchange patient medical record information between VA and DOD
electronically,
* adopt governmentwide information technology standards for health
records,
* develop a plan for VA to use DOD's enrollment and eligibility data,
* establish the DSS program,
* develop a graduate medical education pilot program,
* increase nongraduate medical education training and education
opportunities,
* utilize one examination for separating servicemembers that meets the
needs of VA and DOD, and:
* purchase medical supplies and equipment jointly.[Footnote 41]
OMB uses a color code--green, yellow, and red--to score the current
status and progress of health care resource-sharing activities. A score
in the green status would indicate that the departments are achieving
the degree of health care resource sharing agreed upon by the
departments and the administration. Yellow status means the
coordination of VA and DOD health care resource-sharing activities are
yielding mixed results and not meeting their timelines. A red score
would indicate that the departments are not achieving the degree of
health care resource sharing agreed upon by the departments and the
administration. Since OMB first began scoring the departments in 2001,
the score for "current status" of health care resource sharing has
remained yellow and the score for "progress in implementation" has
dropped from the best score of green to a score of yellow.
VA and DOD Lack Useful Performance Measures to Evaluate Health Care
Resource Sharing:
VA and DOD health care resource-sharing activities are guided by a
joint strategic plan--the VA/DOD Joint Strategic Plan, December 2004.
However, the plan does not contain performance measures that are useful
for evaluating how well the departments are achieving their health care
resource-sharing goals.
For example, the plan mentions 30 measures that could be used to assess
the departments' progress in sharing health care resources. We reviewed
the plan and found that the measures could be placed into one of three
categories: (1) a measurement that would be developed in the future,
(2) a measurement that took place only once, and (3) a measurement that
was taken periodically.
We placed 5 of the 30 measures in the first category because the plan
states that these measures will be developed in the future. For
example, the plan states that a communication effectiveness measure
will be developed as part of the communication strategy. The plan also
states that VA and DOD will develop performance measures related to
joint education and training opportunities by December 2006.
Further, we placed 11 of the 30 measures in the second category because
they call for a single event measurement, such as "increase the number
of collaborative research projects completed by VA and DOD by December
2007," or they state a goal, such as a system "will be fully
operational and providing VA benefit eligibility information by
December 2008." While measurements of this type may provide useful
snapshot information of output for a point-in-time prospective, they
are not periodic and thus do not provide long-term or longitudinal
information for evaluating the usefulness of specific activities.
Finally, in the third category we placed the plan's remaining 14
measures that call for periodic measurement. We found there was
variation in the rigor or specificity in the types of data to be
collected or the analysis to be performed. For example, CPC is tasked
with reporting to JEC quarterly; however the tasking does not specify
the types of data to be collected or the analytical assessments to be
performed. Another performance measure from the plan states that the
"Amount of electronic health data available to the other department is
higher each quarter reported." The lack of specificity with this
performance measure raises questions about the usefulness of the
information for evaluating how well the departments are achieving their
health care resource-sharing goals.
Furthermore, VA and DOD have not established a performance measure that
would track their progress in jointly obtaining health care services--
such as difficult-to-fill occupations, laboratory tests, and diagnostic
equipment. For example, while VA and DOD are in the process of jointly
acquiring five MRI units to help with their diagnostic needs through
the JIF program, other opportunities for sharing MRI units may exist.
During our review, we did not find evidence that VA and DOD top
management set an expectation for their medical facility managers to
consider partnering prior to purchasing MRI equipment. Without such an
expectation and a specific measurement tool or metric to track the
joint acquisition and utilization of MRI services, VA and DOD are not
in a position to determine on a nationwide basis the most cost-
efficient way to obtain and deliver MRI services.
Conclusions:
When the idea of health care resource sharing was originally conceived
and sanctioned by the Congress in the early 1980s, it was based on the
premise of excess capacity. However, the set of circumstances that
confront VA and DOD today are quite different, as both departments
strive to serve an increasing number of beneficiaries. VA and DOD
officials state that many of their facilities are at capacity or exceed
capacity. The nature of sharing has shifted from one of utilizing
untapped resources to one of partnering and gaining efficiencies by
leveraging resources or buying power jointly. Implementing such a
process across all components involved with the delivery of VA and DOD
health care should yield positive results as resource sharing becomes
an integral part of a systemwide decision-making process. However,
while VA and DOD, through JEC and HEC, have created mechanisms that
support the potential to increase collaboration, sharing, and
coordination of management and oversight of health care resources and
services, more can be done to capitalize on this relationship
throughout the departments.
The Congress provided additional sharing opportunities for local
entities through the establishment of JIF and DSS. These programs have
laid the foundation for new sharing relationships and, in other cases,
have deepened existing relationships. The goals of each of the projects
are aligned with VA's and DOD's goals to jointly acquire, deliver, and
improve health care services. Both the JIF and DSS programs provide a
congressionally driven mechanism to help increase the number of new
sharing agreements between VA and DOD partners. However, VA and DOD
have not yet developed a standardized evaluation plan for documenting
and recording the advantages and disadvantages of each project and
whether they can be replicated at other VA and DOD medical facilities.
Without an established evaluation plan to measure and determine the
results of the projects, VA and DOD may lose an opportunity to obtain
information that will be useful for determining whether projects can be
replicated systemwide.
The Joint Strategic Plan is a positive first step toward outlining VA
and DOD sharing goals and measures. However, useful specific
quantitative performance measures for VA and DOD to track the progress
of their health care resource-sharing activities have not been
established. Such measures would be a useful tool for VA and DOD to
help ensure that health care sharing is optimized and that the
departments are cost efficiently achieving their resource-sharing
goals.
Recommendations for Executive Action:
To further advance health care resource sharing within VA and DOD, the
Secretaries of Veterans Affairs and Defense should direct JEC and HEC
to take the following two actions:
* develop an evaluation plan for documenting and recording the reasons
for the advantages and disadvantages of each DSS project, an activity
that will assist VA and DOD in replicating successful projects
systemwide, and:
* develop performance measures that would be useful for determining the
progress of their health care resource-sharing goals.
Agency Comments and Our Evaluation:
We received comments from VA and DOD on a draft of this report. The
departments concurred with our recommendations and also provided
technical comments that we have incorporated as appropriate. VA's
comments are included as appendix V and DOD's comments are included as
appendix VI.
VA and DOD agreed with our recommendation to develop a DSS evaluation
plan and described their plans and timelines for implementing it. The
departments stated they have modified an in-progress review template to
strengthen department information on the advantages and disadvantages
of each project and whether they can be replicated systemwide.
According to the departments, the template was distributed to the DSS
sites in January 2006 and will be operational in the second quarter of
fiscal year 2006.
VA and DOD also agreed with our recommendation to develop performance
measures that would be useful for determining the progress of achieving
health care resource-sharing goals. In their comments, the departments
stated that they have, since the work was completed for this report,
issued the VA/DOD Joint Executive Council Strategic Plan, Fiscal Years
2006-2008 (signed by VA and DOD on January 26, 2006)--a plan that
revises and updates the VA/DOD Joint Strategic Plan, December 2004 and
contains performance measures that demonstrate measurable progress
relative to specific strategic milestones. VA included a copy of the
updated plan with its comments and noted that action on this
recommendation has been completed as performance measures have been
identified for each of the health care resource-sharing goals. We do
not agree that the January 2006 plan fully addresses the concerns
raised in the report, and maintain our recommendation that useful
measures--those that provide specifics regarding time frames,
implementation strategies, and the type of information that will be
reported to program managers--need to be developed. For example, our
review of the Joint Strategic Plan, Fiscal Years 2006-2008, showed that
while goal 6--Joint Medical Contingency/Readiness Capabilities--has
strategies and key milestones, it contained no performance measures for
monitoring progress toward achieving the stated goal. Furthermore, 6 of
the plan's 22 performance measures call for one point-in-time
measurement and thus do not provide longitudinal information for
evaluating the usefulness of specific activities.
We are sending copies of this report to the Secretaries of Veterans
Affairs and Defense, appropriate congressional committees, and other
interested parties. We will also make copies available to others upon
request. In addition, the report is available at no charge on the GAO
Web site at http://www.gao.gov.
If you or your staff have questions about this report, please contact
me at (202) 512-7101 or ekstrandl@gao.gov. Contact points for our
Office of Congressional Relations and Public Affairs may be found on
the last page of this report. Michael T. Blair, Jr., Assistant
Director; Aditi Archer; Jessica Cobert; Kevin Milne; and Julianna
Williams made key contributions to this report.
Signed by:
Laurie E. Ekstrand:
Director, Health Care:
List of Committees:
The Honorable John Warner:
Chairman:
The Honorable Carl Levin:
Ranking Minority Member:
Committee on Armed Services:
United States Senate:
The Honorable Larry E. Craig:
Chairman:
The Honorable Daniel K. Akaka:
Ranking Minority Member:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Duncan Hunter:
Chairman:
The Honorable Ike Skelton:
Ranking Minority Member:
Committee on Armed Services:
House of Representatives:
The Honorable Steve Buyer:
Chairman:
The Honorable Lane Evans:
Ranking Minority Member:
Committee on Veterans' Affairs:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
To assess the Department of Veterans Affairs' (VA) and Department of
Defense's (DOD) progress in implementing the Joint Incentive Fund (JIF)
and Demonstration Site Selection (DSS) programs, including whether they
are operational, we visited VA and DOD medical facilities at six sites-
-Augusta, Georgia; Honolulu, Hawaii; North Chicago, Illinois; El Paso,
Texas; San Antonio, Texas; and Puget Sound, Washington, and interviewed
department officials responsible for the development and implementation
of each of the projects and conducted site visits at select sites. In
addition, we contacted VA and DOD officials from seven additional
sharing sites.[Footnote 42] For all of the sites, we reviewed approved
business case analyses for JIF projects selected in fiscal year 2004
and DSS projects that included detailed descriptions of the projects,
timelines for development and implementation, associated risks, costs,
potential cost savings (if applicable), staffing requirements, and
quarterly progress reports. We also obtained and reviewed VA and DOD
policies governing sharing and reviewed relevant department reports,
including those from the DOD Inspector General and DOD contractors,
along with our prior work.
To obtain information on the actions taken by VA and DOD to strengthen
the sharing of health care resources, we interviewed officials from
VA's Office of Policy, Planning, and Preparedness and the Veterans
Health Administration--including the VA/DOD Liaison Office and VA
medical center (VAMC) staff at several locations engaged in the sharing
of health care resources. We interviewed officials from DOD's TRICARE
Management Activity;[Footnote 43] DOD/VA Program Coordination Office;
the military services' surgeons general offices, which coordinate
sharing activities; and several military treatment facilities (MTF)
engaged in the sharing of health care resources. We also interviewed
officials from Joint Executive Council (JEC) committees and Health
Executive Council (HEC) workgroups[Footnote 44] to determine what
policies, procedures, and guidance have been promulgated to promote
health care resource sharing and coordination between VA and DOD.
Further, we spoke with officials from the Office of Management and
Budget (OMB). We reviewed the charters, when available, and briefing
updates for each JEC committee and HEC workgroup and OMB's scorecards
for the President's Management Agenda initiative directed at VA and DOD
sharing. We analyzed sharing data between VA and each branch of service
that included workload, sharing agreements, and cost data. We also
reviewed the actions taken by both VA and DOD to strengthen the sharing
of health care resources. In addition, we evaluated whether health care
resource-sharing activities were considered as part of Capital Asset
Realignment for Enhanced Services and base realignment and closure
decisions.
To assess whether VA and DOD performance measures are useful, we
interviewed officials from VA's Office of Policy, Planning, and
Preparedness and the Veterans Health Administration--including the
VA/DOD Liaison Office and VAMC staff at several locations engaged in
the sharing of health care resources. We also interviewed officials
from DOD's TRICARE Management Activity; the DOD/VA Program Coordination
Office; the military services' surgeons general offices, which
coordinate sharing activities; and several MTF locations engaged in the
sharing of health care resources. We analyzed the VA/DOD joint
strategic plan,[Footnote 45] VA's strategic plan,[Footnote 46] DOD's
Military Health System Strategic Plan,[Footnote 47] VA's performance
and accountability report,[Footnote 48] DOD's performance and
accountability report,[Footnote 49] and VA/DOD's annual report to the
Congress on sharing.[Footnote 50]
We conducted our work from January 2005 through March 2006 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Joint Incentive Fund Program:
JIF fiscal year 2004 projects.
VA partner: VA Pacific Islands Health Care System, Hawaii;
DOD partner: Tripler Army Medical Center, Hawaii;
Project description: Delta Systems II-Cad/Cam System: This is a
fabrication technology system that produces molds for prosthetics and
orthotics from lightweight foam through use of a laser scanner and
mill. Installing this device at Tripler should allow for greater
patient access; reduce clinic visits for casting, adjustments, and
fittings; and allow for an increase in VA beneficiary access;
Dollar amount of project: $542,000.
VA partner: Fargo Veterans Affairs Medical Center, North Dakota;
DOD partner: 319th Medical Group, Grand Forks Air Force Base, North
Dakota;
Project description: Joint TeleMental System: Acquiring
videoconferencing technology should allow VA to provide mental health
services to DOD beneficiaries approximately 80 miles away;
Dollar amount of project: $14,000.
VA partner: VA Northern California Health Care System, California;
DOD partner: 60th Medical Group, Travis Air Force Base, California;
Project description: Joint Dialysis Unit: Through upgrading equipment
and increased staffing, Travis Air Force Base's dialysis unit is
expected to be able to accommodate VA beneficiaries;
Dollar amount of project: $1,568,560.
VA partner: North Chicago Veterans Affairs Medical Center, Illinois;
DOD partner: Naval Hospital Great Lakes, Illinois;
Project description: Mammography Unit Expansion: The purchase of new
digital mammography equipment, a stereotactic unit, and hiring of
support staff should now reduce wait times for DOD beneficiaries and
allow for VA beneficiary access;
Dollar amount of project: $655,000.
VA partner: Spokane Veterans Affairs Medical Center, Washington;
DOD partner: 92nd Medical Group, Fairchild Air Force Base, Washington;
Project description: Teleradiology Initiative: This will upgrade DOD's
system so it can download images from VA for radiological
interpretation and is intended to allow VA to provide computed
tomography scans for DOD patients;
Dollar amount of project: $333,537.
VA partner: North Chicago Veterans Affairs Medical Center, Illinois;
DOD partner: Naval Hospital Great Lakes, Illinois;
Project description: Women's Health Center: This project proposes to
create a comprehensive women's health center for VA and DOD
beneficiaries by coordinating women's services and includes hiring
gynecology, wellness, and case management staff;
Dollar amount of project: $1,315,332.
VA partner: Alaska Veterans Affairs Health Care System, Alaska;
DOD partner: 3rd Medical Group, Elmendorf Air Force Base, Alaska;
Project description: Enhanced Outpatient Diagnostic Services: The
acquisition of diagnostic equipment is intended to provide in-house
imaging services to VA and DOD beneficiaries;
Dollar amount of project: $535,000.
VA partner: Syracuse Veterans Affairs Medical Center, New York;
DOD partner: Fort Drum, New York;
Project description: Telepsychiatry: The hiring of a full-time VA
psychiatrist is intended to allow VA to provide mental health services
to DOD patients via videoconferencing;
Dollar amount of project: $330,000.
VA partner: Robert J. Dole Veterans Affairs Medical Center, Kansas;
DOD partner: 22nd Medical Group, McConnell Air Force Base, Kansas;
Project description: Cardiac Catheterization Laboratory: Remodeling
existing VA space is intended to accommodate new equipment and provide
in-house cardiac services to VA and DOD beneficiaries;
Dollar amount of project: $3,539,722.
VA partner: Dorn Veterans Affairs Medical Center, South Carolina;
DOD partner: Moncrief Army Community Hospital and 20th Medical Group,
Shaw Air Force Base, South Carolina;
Project description: Expansion of Existing Magnetic Resonance Imaging
Joint Venture: The acquisition of an open magnetic resonance imaging
unit located at Moncrief Army Community Hospital is intended to provide
in-house services to VA and DOD beneficiaries;
Dollar amount of project: $2,014,000.
VA partner: South Texas Veterans Health Care System, Texas;
DOD partner: Wilford Hall Medical Center, Texas;
Project description: North Central San Antonio Clinic: The
establishment of a joint VA/DOD clinic is intended to provide greater
access for VA and DOD beneficiaries;
Dollar amount of project: $11,974,197.
JIF fiscal year 2005 projects:
VA partner: Veterans Health Administration Central Office;
DOD partner: DOD TRICARE Management Activity;
Project description: Medical Enterprise Web Portals: The project is
designed to standardize VA and DOD's Web portals--they both will have
the same "look and feel" to them from a beneficiary perspective,
including a requirement that each portal meets national standards
regarding accessibility for people with disabilities;
Dollar amount of project: $2,501,000.
VA partner: Veterans Health Administration Central Office;
DOD partner: Defense Supply Center, Philadelphia;
Project description: Medical/Surgical Supply Data Sync: This project is
intended to create a joint VA and DOD medical/surgical supply catalog.
According to the project plan, the catalog will ultimately allow VA and
DOD to jointly identify common medical/surgical products procured and
maximize joint buying power for these products through negotiated
volume purchase contracts;
Dollar amount of project: $4,500,000.
VA partner: Louisville Veterans Affairs Medical Center, Kentucky;
DOD partner: Ireland Army Community Hospital, Fort Knox, Kentucky;
Project description: Radiology: The hiring of additional radiologists
is intended to fully utilize existing equipment and provide greater
access for VA and DOD beneficiaries;
Dollar amount of project: $1,185,684.
VA partner: Harry S. Truman Memorial Veterans' Hospital, Missouri;
DOD partner: General Leonard Wood Army Community Hospital and 509th
Medical Group, Whiteman Air Force Base, Missouri;
Project description: Sleep Lab Expansion: The renovation and expansion,
from two beds to four beds, of the VA Sleep Diagnostic and Treatment
Lab is intended to decrease wait times for VA beneficiaries and allow
for DOD beneficiary access;
Dollar amount of project: $436,113.
VA partner: Veterans Affairs Puget Sound Health Care System,
Washington;
DOD partner: Madigan Army Medical Center, Washington;
Project description: Cardiac Surgery: The consolidation of VA and DOD
cardiac surgery programs into a coordinated single large cardiac
program is intended to improve quality of care for VA and DOD
beneficiaries while achieving efficiencies and economies of scale;
Dollar amount of project: $1,626,427.
VA partner: Veterans Affairs Puget Sound Health Care System,
Washington;
DOD partner: Madigan Army Medical Center, Washington;
Project description: Neurosurgery Program: This project is intended to
improve the provision of neurosurgical care to VA and DOD beneficiaries
by jointly recruiting neurosurgeons;
Dollar amount of project: $716,000.
VA partner: Veterans Affairs Pacific Islands Health Care System,
Hawaii;
DOD partner: Tripler Army Medical Center, Hawaii;
Project description: Dialysis: By providing the staff necessary to
optimally utilize an existing DOD dialysis center, this project is
intended to increase access for VA beneficiaries;
Dollar amount of project: $2,752,942.
VA partner: Veterans Affairs Pacific Islands Health Care System,
Hawaii;
DOD partner: Tripler Army Medical Center, Hawaii;
Project description: Pain Management Improvement: Converting an
anesthesiologist who specializes in pain rehabilitation from part-time
to full-time is intended to recapture pain management workload that is
currently being outsourced and decrease beneficiary wait times;
Dollar amount of project: $707,000.
VA partner: North Chicago Veterans Affairs Medical Center, Illinois;
DOD partner: Naval Hospital Great Lakes, Illinois;
Project description: Joint Magnetic Resonance Imaging: The acquisition
of an open field magnetic resonance imaging unit and the hiring of a
radiologist are intended to reduce patient wait time, referrals for
contract care, delays in treatment, and length of stay for acutely ill
patients;
Dollar amount of project: $3,449,000.
VA partner: North Chicago Veterans Affairs Medical Center, Illinois;
DOD partner: Naval Hospital Great Lakes, Illinois;
Project description: Clinical Fiber-Optics: By providing the necessary
high-speed clinical connectivity between VA and DOD facilities, this
project is intended to provide the bandwidth needed to transmit
clinical images to VA;
Dollar amount of project: $247,245.
VA partner: North Chicago Veterans Affairs Medical Center, Illinois;
DOD partner: Naval Hospital Great Lakes, Illinois;
Project description: Oncology: This project is intended to create a
hematology-oncology program for VA and DOD beneficiaries, who are
currently referred to the local community;
Dollar amount of project: $600,000.
VA partner: South Texas Veterans Health Care System, Texas;
DOD partner: Wilford Hall Medical Center and Brooke Army Medical
Center, Texas;
Project description: Digital Imaging: The seamless sharing of digital
images, texts, and patient demographic information between clinical VA
and DOD systems is intended to be a pilot data exchange program;
Dollar amount of project: $3,450,000.
VA partner: South Texas Veterans Health Care System, Texas;
DOD partner: Wilford Hall Medical Center and Brooke Army Medical
Center, Texas;
Project description: Hyperbaric Medicine: Modifications to the DOD
facility to allow for the installation of a hyperbaric chamber that is
intended to provide greater access and decrease surgical wait times for
VA and DOD beneficiaries;
Dollar amount of project: $1,170,000.
VA partner: Cheyenne and Sheridan Veterans Affairs Medical Centers,
Wyoming;
DOD partner: F. E. Warren Air Force Base, Wyoming;
Project description: Mobile Magnetic Resonance Imaging: This project is
intended to provide access to VA and DOD beneficiaries through the
acquisition of a mobile magnetic resonance imaging unit;
Dollar amount of project: $2,000,000.
VA partner: Boise Veterans Affairs Medical Center, Idaho;
DOD partner: 366th Medical Group, Mountain Home Air Force Base, Idaho;
Project description: Mobile Magnetic Resonance Imaging: Site
preparation and the acquisition of a mobile magnetic resonance imaging
unit along with a digital printer are intended to recapture magnetic
resonance imaging exams that are currently purchased in the local
community, thereby improving access for VA and DOD beneficiaries;
Dollar amount of project: $2,090,000.
VA partner: Veterans Integrated Service Network Support Service Center;
DOD partner: Air Force Medical Operations Agency;
Project description: Healthcare Planning Data Mart: This project plans
to develop a joint VA and Air Force database to capture the amount of
care each contracts for outside of its respective health care system.
Through the creation of the database, VA and Air Force managers hope to
identify areas in which they can jointly purchase services and achieve
savings through leveraged buying power;
Dollar amount of project: $1,067,756.
VA partner: Veterans Affairs Black Hills Health Care System, South
Dakota;
DOD partner: 28th Medical Group, Ellsworth Air Force Base, South
Dakota;
Project description: Mobile Magnetic Resonance Imaging: The acquisition
of a mobile magnetic resonance imaging unit is intended to recapture
magnetic resonance imaging exams that are currently purchased in the
local community, thereby improving access for VA and DOD beneficiaries;
Dollar amount of project: $2,000,000.
Sources: VA and DOD.
Note: Projects may be funded over a 2-year period.
[End of table]
[End of section]
Appendix III: Demonstration Site Selection Projects for Fiscal Years
2003 through 2007:
VA partner: Veterans Affairs Pacific Islands Health Care System,
Hawaii;
DOD partner: Tripler Army Medical Center, Hawaii;
Category: Budget and Financial Management System;
Project description: Joint Venture Operations Revenue Cycle--The goal
of this project is to conduct and execute the findings of studies in
four key areas. (1) Health Care Forecasting, Demand Management, and
Resource Tracking: Define, test and implement a system that will
combine VA and DOD data for beneficiaries receiving care in the Pacific
Islands joint venture market. This will include all eligibility,
insurance, administrative, clinical, staffing, and costing data that
will allow VA and DOD to query and output information on utilization
and demand, supply and capacity, combined costs, facility and staff,
services, and beneficiary population. (2) Referral Management and Fee
Authorization: Define, test, and implement a system that will provide
the capability of timely tracking of authorizations, obligations, and
provisions of clinical care to beneficiaries referred from one
department to the other. (3) Joint Charge Master Based Billing: Define,
test, and implement a system that will provide DOD with the capability
for itemized billing and patient-level costing. (4) Document
Management: Define, test, and implement a system that gives VA and DOD
the capability to support all the business and clinical processes of
sharing care;
Estimated total dollar amount of project: $4,152,000.
VA partner: Alaska Veterans Affairs Health Care System, Alaska;
DOD partner: 3rd Medical Group, Elmendorf Air Force Base, Alaska;
Category: Budget and Financial Management System;
Project description: Joint Venture Business Directorate--This project
intends to achieve the following goals: (1) Through the use of a joint
business office, evaluate areas of business collaboration as VA moves
its main operation next door to the existing joint venture hospital.
Areas for possible sharing include library, warehouse, radiology,
ambulatory surgery, central sterile supply, GI procedure space,
education facilities, physical plant utilities, security services, and
patient transportation. (2) Generate itemized bills and utilize the
existing VA fee program to capture workload and patient-specific health
information. (3) Create a coordinated calculation of cost-based
expenses to assist in market area procurement decisions;
Estimated total dollar amount of project: $4,782,000.
VA partner: Augusta Veterans Affairs Medical Center, Georgia;
DOD partner: Eisenhower Army Medical Center, Georgia;
Category: Coordinated Staffing and Assignment System;
Project description: Joint Staffing--VA and DOD plan to jointly to
recruit, hire, and train staff for difficult-to-fill direct patient
care occupations, which provide clinical and ancillary support
services. Specifically, the project is designed to (1) utilize the
Augusta VAMC's successful recruitment initiatives to aid DOD in hiring
staff for direct patient care positions it has been unable to fill, (2)
unite training initiatives so direct patient care staff may take
advantage of training opportunities at either facility, and (3) hire
and train a select group of staff that would service either facility
when a critical staffing shortage occurred;
Estimated total dollar amount of project: $2,880,000.
VA partner: Hampton, Veterans Affairs Medical Center, Virginia;
DOD partner: 1st Medical Group, Langley Air Force Base, Virginia;
Category: Coordinated Staffing and Assignment System;
Project description: Coordinated Staffing Initiative--The goals of this
project are intended to achieve the following: (1) Develop a process to
identify department- specific needs to address staffing shortfalls for
integrated services. (2) Create a method to compare, reconcile, and
integrate requirements between facilities. (3) Determine a payment
methodology to support the procurement process for staffing shortfalls.
(4) Establish a joint referral and appointment process, to include
allocation of capacity and prioritization of workload. (5) Maintain an
ongoing assessment of issues and problem resolution;
Estimated total dollar amount of project: $780,000.
VA partner: Veterans Affairs Puget Sound, Health Care System,
Washington;
DOD partner: Madigan Army Medical Center, Washington;
Category: Medical Information/Information Technology Management System;
Project description: Health Care Data Exchange--The goal of this
project is to transmit a limited subset of currently available clinical
data between VA and DOD. The intent of this project is to work with the
developers of Composite Health Care System II (CHCS II), Bidirectional
Health Information Exchange (BHIE), and Computerized Patient Record
System, to exchange and view data such as discharge summaries;
Estimated total dollar amount of project: $14,865,000.
VA partner: El Paso Veterans Affairs Health Care System, Texas;
DOD partner: William Beaumont Army Medical Center, Texas;
Category: Medical Information/Information Technology Management System;
Project description: Laboratory Data Sharing--with CHCS II
modifications: Phase I is the implementation of the Laboratory Data
Sharing Initiative (LDSI) with the CHCS II modification. LDSI
implementation is intended to eliminate rekeying of orders entered by
VA providers in VA's Veterans Health Information Systems and Technology
Architecture (VISTA) into DOD's CHCS II, decrease errors caused by
transcription, and increase speed of lab results availability to VA
providers for treatment purposes. Phase II will be the implementation
of the BHIE project, which is currently being deployed, with the CHCS
II modification. Initial focus will be on data sharing related to
patient demographic information, outpatient pharmaceuticals prescribed
to patient populations, and allergy information. Phase III expands on
the initial development of the BHIE project by including the data
sharing of radiology reports (text) and laboratory results, including
anatomic pathology;
Estimated total dollar amount of project: $3,058,000.
VA partner: South Texas Veterans Health Care System, Texas;
DOD partner: Wilford Hall Medical Center and Brooke Army Medical
Center, Texas;
Category: Medical Information/Information Technology Management System;
Project description: Laboratory Data Sharing--VA's VISTA to DOD's
Composite Health Care System I (CHCS I). LDSI is intended to meet the
need of receiving electronic patient test results from reference labs,
thereby eliminating manual data entry of such results. The goal is to
create bidirectional communication between VISTA and CHCS I to
facilitate ordering, sending, and receiving of all lab test subscripts
(including chemistry, anatomic pathology, and microbiology). Tangible
benefits include more efficient use of man- hours from not having to
manually enter test results and improved turnaround time for the
providers to receive results. Intangible benefits include increased
patient safety via the elimination of manual test results;
Estimated total dollar amount of project: $3,923,000.
VA partner: South Texas Veterans Health Care System, Texas;
DOD partner: Wilford Hall Medical Center and Brooke Army Medical
Center, Texas;
Category: Medical Information/Information Technology Management System;
Project description: Joint Credentialing System--VA and DOD plan to
jointly credential licensed providers based on an interface between
DOD's Centralized Credentials Quality Assurance System (CCQAS) and
VetPro, VA's credentialing system. The project is divided into four
phases: Phase I-Implement the current version of CCQAS that is
available at the time of implementation with the interface. Phase II-
Create a means to provide the capability to view credentialing files
and scanned primary source verification documentation in either system
by VA or DOD staff. Phase III-Expand the use of credentialing in VetPro
at VA and CCQAS at DOD to include nurses and other licensed
professionals. Phase IV-Explore the feasibility of a local centralized
site for primary source verification;
Estimated total dollar amount of project: $2,554,000.
Sources: VA and DOD.
[End of table]
[End of section]
Appendix IV: Description of VA's and DOD's Councils, Committees, and
Workgroups:
Joint Executive Council (JEC): Established in February 2002, VA and
DOD's JEC was created to enhance VA and DOD collaboration, ensure the
efficient use of federal resources, remove barriers and address
challenges that impede collaborative efforts, assert and support
mutually beneficial opportunities to improve business practices, and
develop a joint strategic planning process to guide the direction of
sharing activities. JEC is co-chaired by the Deputy Secretary of
Veterans Affairs and the Under Secretary of Defense for Personnel and
Readiness. Membership consists of senior leaders from both VA and DOD,
including VA's Under Secretary for Benefits and Under Secretary for
Health and DOD's Principal Deputy Under Secretary of Defense for
Personnel and Readiness and Assistant Secretary for Health Affairs. JEC
has two interagency councils and two interagency committees to further
facilitate collaboration and sharing opportunities: (1) the Benefits
Executive Council, (2) the Joint Strategic Planning Committee, (3) the
Construction Planning Committee, and (4) the Health Executive Council.
JEC's primary responsibility is to set strategic priorities for the
four interagency councils and committees, monitor the development and
implementation of the Joint Strategic Plan, and ensure accountability
is incorporated into all joint initiatives.
Benefits Executive Council (BEC): Established by JEC in August 2003,
BEC was charged with examining ways to expand and improve information
sharing, refine the process of records retrieval, identify procedures
to improve the benefits claims process, improve outreach, and increase
servicemembers' awareness of potential benefits. In addition, BEC
provides advice and recommendations to JEC on issues related to
seamless transition from active duty to veteran status through a
streamlined benefits delivery process, including the development of a
cooperative physical examination process and the pursuit of
interoperability and data sharing.
Joint Strategic Planning Committee: Established by JEC in October 2002,
the committee was charged with developing a joint strategic plan that
through specific initiatives, would improve the quality, efficiency,
and effectiveness of the delivery of benefits and services to both VA
and DOD beneficiaries through enhanced collaboration and sharing.
VA/DOD Construction Planning Committee (CPC): Established by JEC in
August 2003, CPC provides a formalized structure to facilitate
cooperation and collaboration in achieving an integrated approach to
capital coordination that considers both short-term and long-term
strategic capital issues. CPC was charged with providing oversight to
ensure that collaborative opportunities for joint capital asset
planning are maximized, and provides the final review and approval of
all joint capital asset initiatives recommended by any element of JEC
structure.
Health Executive Council (HEC): In 1997, VA and DOD established HEC--a
precursor to JEC. HEC was co-chaired by the VA Under Secretary for
Health and the Assistant Secretary of Defense (Health Affairs). JEC
rechartered HEC in August 2003 to oversee the cooperative efforts of
each department's health care organizations. HEC has charged workgroups
to focus on specific high-priority areas of national interest. HEC has
organized itself into 11 workgroups to carry out its mission--to
institutionalize VA and DOD sharing and collaboration through the
efficient use of health services and resources.
HEC Workgroups:
1. Contingency Planning: The workgroup is responsible for developing
collaborative efforts in support of the VA and DOD Contingency Plan and
the National Disaster Medical System. Through the workgroup, VA and DOD
are in the process of jointly updating the memorandum of understanding
regarding VA furnishing health care services to members of the armed
forces during a war or national emergency.
2. Continuing Education and Training: The workgroup is responsible for
developing a shared training infrastructure and for designing,
developing, and managing the operational procedures to facilitate
increased sharing of education and training opportunities between VA
and DOD.
3. Deployment Health: The workgroup is responsible for enhancing health
care available to servicemembers returning from overseas deployment.
Focusing on health risks associated with specific deployments, the
group developed proactive approaches toward deployment health
surveillance, health risk communication, and early identification and
treatment of deployment-related health problems.
4. Evidence-Based Practice Guidelines: The workgroup is responsible for
the creation and publication of jointly used guidelines for disease
management.
5. Financial Management: The workgroup is responsible for developing
and disseminating principles and procedures, interpreting current
policies and guidance, establishing policies to be used in creating
reimbursable arrangements, and resolving disputed issues related to
such arrangements that cannot be resolved at local or intermediate
organizational levels. The workgroup is also responsible for the
implementation of JIF.
6. Graduate Medical Education (GME): The workgroup is responsible for
reviewing the current state of the GME[Footnote 51] program between
both departments, and implementing the joint pilot program for GME
under which graduate medical education and training is provided to
military physicians and physician employees of DOD and VA through one
or more programs carried out in DOD's military MTFs and VAMCs, as
mandated by legislation in December 2002.[Footnote 52]
7. Joint Facility Utilization and Resource Sharing: The workgroup is
responsible for examining issues such as removing barriers to resource
sharing and streamlining the process for approving sharing agreements.
The workgroup was originally tasked with identifying areas for improved
resource utilization through local and regional partnerships, assessing
the viability and usefulness of interagency clinical agreements,
identifying impediments to sharing, and identifying best practices for
sharing resources. The workgroup was responsible for providing
oversight of the DOD/VA Joint Assessment Study mandated by the
Department of Defense and Emergency Supplemental Appropriations for
Recovery from and Response to Terrorist Attacks on the United States
Act, 2002.[Footnote 53] The workgroup is also responsible for the
implementation of DSS.
8. Information Management/Information Technology: The workgroup is
responsible for developing interfaces and implementing standards to
facilitate interoperability for improving exchange of health data
between VA and DOD.
9. Medical Materiel Management: In lieu of a charter, VA and DOD
officials signed a memorandum of agreement. Under the terms of the
memorandum, the workgroup is to "combine identical medical supply
requirements from both agencies and leverage that volume to negotiate
better pricing."
10. Patient Safety: The workgroup is responsible for reviewing and
developing internal and external reporting systems for patient safety.
DOD has established a Patient Safety Center at the Armed Forces
Institute of Pathology using the VA National Center for Patient Safety
as a model.
11. Pharmacy: The workgroup is responsible for expanding participation
by the VA Pharmacy Benefits Management Strategic Health Care Group and
the DOD Pharmacoeconomic Center to evaluate high-dollar and high-volume
pharmaceuticals jointly. According to the workgroup, it is overseeing
joint actions, such as joint contracts involving high-dollar and high-
volume pharmaceuticals, which are designed to increase uniformity and
improve the clinical and economic outcomes of drug therapy in the VA
and DOD health systems. The workgroup's goals include eliminating
unnecessary redundancies that exist in areas of class reviews,
contracting prescribing guidelines, and utilization management.
[End of section]
Appendix V: Comments from the Department of Veterans Affairs:
THE DEPUTY SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:
February 27, 2006:
Ms. Laurie E. Ekstrand:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Ekstrand:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VA AND DOD HEALTH CARE:
Opportunities to Maximize Resource Sharing Remain (GAO-06-315). The
Department agrees with GAO's overall findings and generally concurs
with the recommendations. The enclosure provides additional discussion
on the recommendations.
VA appreciates the opportunity to comment on your draft report.
Sincerely yours,
Signed by:
Gordon H. Mansfield:
Enclosure:
THE DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT:
VA AND DOD HEALTH CARE. Opportunities to Maximize Resource Sharing
Remain (GAO 06-315):
To further advance resource sharing within VA and DOD, the Secretaries
of Veterans Affairs and Defense should direct the JEC and HEC to:
* Develop an evaluation plan for documenting and recording the reasons
for the advantages and disadvantages of each DSS project, an activity
that will assist VA and DOD in replicating successful projects system-
wide.
Concur:
The Health Executive Council (HEC) Joint Facility Utilization and
Resource Sharing Workgroup provides direct oversight over the DSS
projects, and has developed a plan to measure the effectiveness and
evaluate the advantages and disadvantages of each DSS project. The plan
includes development of a template guide to improve the comprehensive,
quarterly Interim Project Reviews (IPR). Workgroup members also
participate in weekly or bi-weekly meetings with the DSS project teams
to track progress. Subject matter experts from other HEC workgroups,
such as those involved with information management and technology,
provide appropriate assistance and expertise as necessary. The new IPR
template has been modified to capture input about the advantages and
disadvantages of projects system wide. It was distributed to the
demonstration sites in January 2006 and is expected to be implemented
with the second quarter Fiscal Year (FY) 2006 Interim Project Review.
The Joint Facility Utilization and Resource Sharing Workgroup has also
developed a Standard Operating Procedure (SOP) and template to collect
and catalogue a selection of lessons learned that can be applied to
ongoing project implementation. This template was disseminated to the
DSS sites in the Fall of 2005. The lessons learned repository will
enable the DSS staff to consolidate and analyze lessons learned,
identify trends, and facilitate development of guidance for replicating
projects. DOD has advised that they will submit a copy of the plan with
their comments to GAO.
This is in process.
* Develop performance measures that would be useful for determining the
progress of their resource sharing goals.
Concur:
As noted in the attached VA/DOD Joint Executive Council Strategic Plan
(FYs 2006-2008), performance measures have been identified for each of
the resource sharing goals.
This has been completed.
[End of section]
Appendix VI: Comments from the Department of Defense:
THE ASSISTANT SECRETARY OF DEFENSE:
HEALTH AFFAIRS:
WASHINGTON, D. C. 20301-1200:
FEB 27 2006:
Ms. Laurie E. Ekstrand:
Director, Health Care:
U.S. Government Accountability Office:
441 G. Street, N.W.
Washington, DC 20548:
Dear Ms. Ekstrand:
This is the Department of Defense response to the Government
Accountability Office (GAO) draft report, GAO 06-315, "VA AND DOD
HEALTH CARE: Opportunities to Maximize Resource Sharing Remain," dated
February 7, 2006 (GAO Code 290277).
The Department appreciates the opportunity to comment on the draft
report and concurs with the GAO findings and recommendations with the
enclosed comments.
Please direct any questions to my points of contact on this matter, Mr.
Kenneth Cox (functional) at (703) 681-0039, ext. 3602 and Mr. Gunther
J. Zimmerman (Audit Liaison) at (703) 681-3492, ext. 4065.
Sincerely,
Signed for:
William Winkenwerder, Jr., MD:
Enclosure: As stated:
GAO DRAFT REPORT - DATED FEBRUARY 7, 2006
GAO CODE - 290277/GAO-06-315:
"VA AND DOD HEALTH CARE: OPPORTUNITIES TO MAXIMIZE RESOURCE SHARING
REMAIN"
DEPARTMENT OF DEFENSE COMMENTS:
This draft report provides a review of the Department of Veterans
Affairs' (VA) and Department of Defense's (DoD) progress in
implementing the Joint Incentive Fund (JIF) and Demonstration Site
Selection (DSS) programs required by National Defense Authorization Act
FY2003.
Overall Comments:
* Citing all references to a nationwide integrated review and market
analysis:
- The FY 2008-2013 Program Objective Memorandum/Budget Estimate
Submission Programming Guidance, dated November 14, 2005, requires the
military Services, TRICARE Management Activity, and the TRICARE
Regional Offices to identify opportunities for DoDNA resource sharing
as part of their annual business plans when programming for resources.
- The Air Force and VA are implementing a JIF proposal which is
developing a tool to analyze purchased care in joint Air Force and VA
markets across the country. After the tool is tested with the Air
Force, the Departments plan to expand the initiative to the other two
Services. Additionally, Tripler Army Medical Center (TAMC) is
evaluating the feasibility of the Joint Assessment Study (JAS) model.
The methodologies and crosswalks developed during the JAS are being
used in the development of the VA/Air Force JIF project, creating an
integrated tool.
* Page 29, first paragraph, last sentence - The JAS was disseminated
and briefed to the Service Surgeons General offices and briefed at the
2004 TRICARE Conference. In October 2004, DoD conducted a two and a
half day workshop at TAMC instructing how to use the JAS methodology.
It is also available on DoDNA website:
http://www.tricare.osd.mil/DVPCO/reports.cfm.
DEPARTMENT OF DEFENSE COMMENTS TO THE RECOMMENDATIONS:
RECOMMENDATION 1: The GAO recommended that the Secretaries of VA and
DoD should direct the Joint Executive Council (JEC) and the Health
Executive Council (HEC) to develop an evaluation plan for documenting
and recording the reasons for the advantages and disadvantages of each
Demonstration Site Selection (DSS) project, an activity that will
assist VA and DoD in replicating successful projects system-wide. (Page
34/GAO Draft Report):
DOD RESPONSE: DoD concurs with this recommendation. The Joint Facility
Utilization/Resource Sharing Workgroup, under the HEC, has an
evaluation process in place. A "lessons learned" template was
disseminated to the DSS sites in Fall 2005, and the in-progress review
(IPR) template has been modified to strengthen discussion on
advantages, disadvantages, and replicating projects system-wide. The
modified IPR template was distributed to the DSS sites in January 2006
and will be operational in the second quarter of FY06. A Standard
Operating Procedure and template have been developed to gather "lessons
learned". In addition, a "lessons learned" repository is being
developed that will enable the DSS staff to consolidate and analyze
lessons learned, identify trends, facilitate development of guidance
for replicating projects, and improve oversight and management of the
projects.
RECOMMENDATION 2: The GAO recommended that the Secretaries of VA and
DoD should direct the Joint Executive Council and the Health Executive
Council to develop performance measures that would be useful for
determining the progress of their resource sharing goals. (Page 35/GAO
Draft Report):
DOD RESPONSE: DoD concurs with this recommendation. This draft report
commented on the 2005 Joint Strategic Plan (JSP). The JSP for Fiscal
Year 2006-2008 has recently been issued. It revised and updated the
2004 JSP and contains performance measures that demonstrate measurable
progress relative to specific strategic milestones. * Army Comments:
The efforts of the DSS and JIF projects have helped to illustrate the
complexity and challenges of DoDNA healthcare resources sharing. The
concept of volume of sharing needs to be replaced with one of
efficiency and effectiveness of DoDNA sharing. As the DoD continues to
refine and execute its business planning design, the JEC and the HEC
should ensure that DoDNA healthcare resources sharing considerations,
with identified performance measures, be incorporated. The VA should do
the same. This action is more in-line with the reports findings on page
21, Joint Executive Council, 1st sentence and the report's Conclusions,
page 33, 1st sentence.
* Navy Comments: The current performance measures in the VA/DoD JSP
have made significant efforts over the last two years and will continue
to work together to refine the performance measures.
* Air Force Comments: Significant effort has been made to refine the
performance measures in the VA/DoD JSP in the past two years. While we
acknowledge there is still a considerable amount of work to do to
ensure all performance measures are adequate, the recommendation
implies nothing has been done in this area. However, tracking of the
performance metrics requires additional emphasis. Recommend the
recommendation state "The Joint Executive Council and the Health
Executive Council should continue to develop and refine the performance
measures outlined in the Joint Strategic Plan and report to the
Secretaries of Veterans Affairs (VA) and Defense on the progress of
their resource sharing goals semi-annually."
[End of section]
Related GAO Products:
Results-Oriented Government: Practices That Can Help Enhance and
Sustain Collaboration among Federal Agencies. GAO-06-15. Washington,
D.C.: October 21, 2005.
VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth
Transition from DOD Health Care, but Sharing of Health Information
Remains Limited. GAO-05-1052T. Washington, D.C.: September 28, 2005.
Computer-Based Patient Records: VA and DOD Made Progress, but Much Work
Remains to Fully Share Medical Information. GAO-05-1051T. Washington,
D.C.: September 28, 2005.
Mail Order Pharmacies: DOD's Use of VA's Mail Pharmacy Could Produce
Savings and Other Benefits. GAO-05-555. Washington, D.C.: June 22,
2005.
DOD and VA Health Care: Incentives Program for Sharing Health
Resources. GAO-05-310R. Washington, D.C.: February 28, 2005.
VA and DOD Health Care: Resource Sharing at Selected Sites. GAO-04-792.
Washington, D.C.: July 21, 2004.
DOD and VA Health Care: Incentives Program for Sharing Resources. GAO-
04-495R. Washington, D.C.: February 27, 2004.
DOD and VA Health Care: Access for Dual Eligible Beneficiaries. GAO-03-
904R. Washington, D.C.: June 13, 2003.
VA and Defense Health Care: Increased Risk of Medication Errors for
Shared Patients. GAO-02-1017. Washington, D.C.: September 27, 2002.
VA and Defense Health Care: Potential Exists for Savings through Joint
Purchasing of Medical and Surgical Supplies. GAO-02-872T. Washington,
D.C.: June 26, 2002.
DOD and VA Pharmacy: Progress and Remaining Challenges in Jointly
Buying and Mailing Out Drugs. GAO-01-588. Washington, D.C.: May 25,
2001.
VA and Defense Health Care: Evolving Health Care Systems Require
Rethinking of Resource Sharing Strategies. GAO/HEHS-00-52. Washington,
D.C.: May 17, 2000.
FOOTNOTES
[1] VA provided health care to an estimated 5.2 million of its 7.4
million enrolled beneficiaries in fiscal year 2004. DOD provided health
care to approximately 8.3 million of the estimated 9.2 million
beneficiaries who were eligible for DOD health care in fiscal year
2004.
[2] Bob Stump National Defense Authorization Act for Fiscal Year 2003,
Pub. L. No. 107-314, § 721, 116 Stat. 2458, 2589-95, required VA and
DOD to establish a joint incentive program to identify and provide
incentives to implement, fund, and evaluate creative health care
coordination and sharing initiatives between VA and DOD. VA and DOD
refer to this program as the Joint Incentive Fund program.
[3] Bob Stump National Defense Authorization Act for Fiscal Year 2003,
Pub. L. No. 107-314, § 722, 116 Stat. 2458, 2595-99, required VA and
DOD to establish the Health Care Resources Sharing and Coordination
Project to serve as a test for evaluating the feasibility, advantages,
and disadvantages of programs designed to improve the sharing and
coordination of health care resources between VA and DOD. VA and DOD
refer to this program as the Demonstration Site Selection program.
[4] We have previously reported on the Joint Incentive Fund program in
fiscal years 2004 and 2005. See GAO, DOD and VA Health Care: Incentives
Program for Sharing Resources, GAO-04-495R (Washington, D.C.: Feb. 27,
2004), and DOD and VA Health Care: Incentives Program for Sharing
Health Resources, GAO-05-310R (Washington, D.C.: Feb. 28, 2005).
[5] We visited VA and DOD medical facilities at six sites--Augusta,
Georgia; Honolulu, Hawaii; North Chicago, Illinois; El Paso, Texas; San
Antonio, Texas; and Puget Sound, Washington.
[6] Those seven additional sharing sites were located in the following
areas: Alaska, California, Kansas, New York, North Dakota, South
Carolina, and Virginia.
[7] Under the JIF program, 12 projects were selected for implementation
for fiscal year 2004, but 1 project was removed due to legal concerns.
For fiscal year 2005, 18 JIF projects were selected, but 1 project was
removed due to asset realignment issues. Under the DSS program, 8
projects were selected.
[8] DOD provides health care through TRICARE--a regionally structured
program that uses civilian contractors to maintain provider networks to
complement health care services provided at MTFs.
[9] VA and DOD established JEC along with four additional interagency
councils/committees to further facilitate collaboration between the
departments. HEC and its workgroups, which are under the purview of
JEC, were developed as a mechanism to specifically further the sharing
of health care resources between VA and DOD.
[10] Originally 12 projects were selected; however, 1 project was
removed due to legal concerns. VA and DOD's offices of general counsel
determined after the selection process that VA and DOD did not possess
legal authority to pursue the project. Subsequently, this project was
removed from the program and funding was reallocated.
[11] In their technical comments to this report the departments stated
that all eight projects are operational. However, a project in Hawaii
is not fully operational. The goal of that project is to conduct and
execute the findings of studies in four key areas: (1) Health Care
Forecasting, Demand Management, and Resource Tracking; (2) Referral
Management and Fee Authorization; (3) Joint Charge Master Based
Billing; and (4) Document Management. The project is not fully
operational since, as DOD reported on February 27, 2006, the policies
and procedures have only been updated in one of the four areas--
Referral Management and Fee Authorization.
[12] In fiscal year 2004, there were approximately 7.4 million veterans
enrolled to receive care from VA. However, not all enrollees seek
health care from VA.
[13] In some cases, DOD beneficiaries may also be eligible for health
care benefits from VA.
[14] Adjusted for inflation, this would equal about $17 billion in
fiscal year 2004.
[15] Adjusted for inflation, this would equal about $17 billion in
fiscal year 2004.
[16] See GAO, DOD and VA Pharmacy: Progress and Remaining Challenges in
Jointly Buying and Mailing Out Drugs, GAO-01-588 (Washington, D.C.: May
25, 2001).
[17] Pub. L. No. 97-174, 96 Stat. 70.
[18] Department of Defense and Emergency Supplemental Appropriations
for Recovery from and Response to Terrorist Attacks on the United
States Act, 2002, Pub. L. No. 107-117, § 8147, 115 Stat. 2230, 2280-81.
[19] Findings and Recommendations from the DOD/VA Joint Assessment
Study presented to Office of Special Programs TRICARE Management
Activity, December 31, 2003, Mitretek Systems.
[20] The combined beneficiary market included VA beneficiaries, DOD
beneficiaries, and beneficiaries eligible for care from both VA and
DOD.
[21] To reimburse civilian physicians, DOD has established a CMAC rate.
It is the amount DOD will pay civilian providers for medical services
for DOD patients.
[22] Bob Stump National Defense Authorization Act for Fiscal Year 2003,
Pub. L. No. 107-314, § 721, 116 Stat. 2458, 2589-95.
[23] GAO, Agencies' Strategic Plans Under GPRA: Key Questions to
Facilitate Congressional Review, GAO/GGD-10.1.16 (Washington, D.C.: May
1997).
[24] GAO, Program Performance Measures: Federal Agency Collection and
Use of Performance Data, GAO/GGD-92-65 (Washington, D.C.: May 4, 1992).
[25] Pub. L. No. 103-62, 107 Stat. 285.
[26] Originally 12 projects were selected; however, 1 project was
removed due to legal concerns. VA and DOD offices of general counsel
determined after the selection process that VA and DOD did not possess
legal authority to pursue the project. Subsequently, this project was
removed from the program and funding was reallocated.
[27] Under the statute, 38 U.S.C. § 8111(d)(2), the funding is not
required to be obligated and expensed within a single fiscal year. The
funds may be obligated and expensed over a multiyear period.
[28] These criteria were used to evaluate fiscal year 2004 proposals;
VA and DOD reported in February 2006 that the criteria have been
slightly refined.
[29] The management of VA's hospitals and other health care facilities
is decentralized to 21 regional networks referred to as Veterans
Integrated Service Networks.
[30] Originally 18 projects were selected; however, 1 project was
removed due to asset realignment issues.
[31] The Congress directed VA and DOD to commence funding in fiscal
year 2004.
[32] DOD commented that the contract was awarded on February 23, 2006.
[33] Pub. L. No. 107-314, § 722(e), 116 Stat. 2595-98.
[34] National Defense Authorization Act for Fiscal Year 2004, Pub. L.
No. 108-136 § 583, 117 Stat. 1392, 1490-92, required VA and DOD to
establish a joint executive committee. VA and DOD use their JEC
structure to fulfill this legislative requirement.
[35] In 1997, VA and DOD established HEC--a precursor to JEC, which was
co-chaired by the VA Under Secretary for Health and the Assistant
Secretary of Defense (Health Affairs). In fiscal year 2002, JEC was
established to further engage VA and DOD senior leadership, including
VA's Deputy Secretary and DOD's Under Secretary for Personnel and
Readiness, who serve as co-chairs for JEC.
[36] On February 27, 2006, DOD stated that the departments have added
an additional workgroup--the Mental Health Workgroup.
[37] Department of Veterans Affairs/Department of Defense, VA/DOD Joint
Strategic Plan (Washington, D.C.: December 2004).
[38] Department of Veterans Affairs, Office of the Secretary, Secretary
of Veterans Affairs CARES Decision (Washington, D.C.: May 2004).
[39] See Defense Base Closure and Realignment Act of 1990, Pub. L. No.
101-510, as amended, codified at 10 U.S.C.A. § 2687 note (2004 Supp.)
[40] GAO, Military Bases: Analysis of DOD's 2005 Selection Process and
Recommendations for Base Closures and Realignments, GAO-05-785
(Washington D.C.: July 1, 2005).
[41] OMB's scorecard for PMA Initiative 14--VA/DOD Sharing--does not
score each of these factors individually, rather it uses them to
develop two composite scores: (1) Current Status and (2) Progress in
Implementation.
[42] Those seven additional sharing sites were located in the following
areas: Alaska, California, Kansas, New York, North Dakota, South
Carolina, and Virginia.
[43] DOD provides health care through TRICARE--a regionally structured
program that uses civilian contractors to maintain provider networks to
complement health care services provided at MTFs.
[44] VA and DOD established JEC along with four additional interagency
councils/committees to further facilitate collaboration between the
departments in areas such as strategic planning and health care. HEC
and its workgroups, which are under the purview of JEC, were developed
as a mechanism to specifically further the sharing of health care
resources between VA and DOD.
[45] Department of Veterans Affairs/Department of Defense, VA/DOD Joint
Strategic Plan (Washington, D.C.: December 2004).
[46] Department of Veterans Affairs, Office of the Secretary, Strategic
Plan 2003-2008 (Washington D.C.: July 2003).
[47] Department of Defense, Military Health System Strategic Plan
(September 2002).
[48] Department of Veterans Affairs, Office of Management, FY 2004
Annual Performance and Accountability Report (Washington, D.C.:
November 2004).
[49] Department of Defense, Performance and Accountability Report,
Fiscal Year 2004 (Nov. 15, 2004).
[50] Department of Veterans Affairs/Department of Defense, VA/DOD Joint
Executive Council Annual Report (Washington, D.C.: December 2004).
[51] GME is the second phase of medical education, and prepares
physicians for practice in a medical specialty or subspecialty.
[52] Pub. L. No. 107-314 § 725, 116 Stat. at 2599.
[53] Pub. L. No. 107-117 § 8147, 115 Stat. 2230, 2280-81.
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