VA and DOD Health Care
Progress Made on Implementation of 2003 President's Task Force Recommendations on Collaboration and Coordination, but More Remains to Be Done Gao ID: GAO-08-495R April 30, 2008Improving collaboration and health resource sharing between the Department of Veterans Affairs (VA) and the Department of Defense (DOD) has been the focus of numerous efforts by Congress and the executive branch for more than two decades. In 1982, Congress passed the Veterans' Administration and Department of Defense Health Resources Sharing and Emergency Operations Act (Sharing Act), which authorized VA and DOD health care facilities to partner and enter into sharing agreements to buy, sell, and barter medical and support services. Since then, Congress has passed additional legislation to continue to promote VA and DOD health resource sharing. However, in previous work we have pointed out continuing barriers to such efforts, including incompatible computer systems that affect the exchange of patient health information, inconsistent reimbursement and budgeting policies, and burdensome processes for approving agreements between the departments. On May 28, 2001, the President established the 15-member President's Task Force to Improve Health Care Delivery for Our Nation's Veterans. The task force's mission was to identify ways to improve coordination and sharing between VA and DOD in order to improve health care for servicemembers and veterans. The task force reviewed barriers and challenges in several areas related to coordination, including leadership, transition to veteran status, and improving quality of health care. In May 2003, it made recommendations to VA and DOD to increase collaboration and coordination between the two departments to improve health care delivery. The task force also recommended that the administration take action through the Department of Health and Human Services (HHS) to help improve VA and DOD collaboration, and that Congress take additional action to improve such collaboration. Other more recent task force and commission reports have voiced similar concerns and identified more areas for improvement. Congress asked us to examine the status of VA and DOD's efforts in implementing the 2003 task force recommendations. Specifically, this report describes the extent to which VA and DOD have implemented the recommendations of the 2003 President's Task Force to Improve Health Care for Our Nation's Veterans related to collaboration and coordination.
In summary, we found that VA and DOD have made progress in implementing the task force recommendations, but more remains to be done to fully implement all task force recommendations. Seven of the recommendations have been fully implemented and 11 have been partially implemented. We could not determine the status of 1 because of insufficient information, and 1 does not require VA or DOD action.
GAO-08-495R, VA and DOD Health Care: Progress Made on Implementation of 2003 President's Task Force Recommendations on Collaboration and Coordination, but More Remains to Be Done
This is the accessible text file for GAO report number GAO-08-495R
entitled 'VA and DOD Health Care: Progress Made on Implementation of
2003 President's Task Force Recommendations on Collaboration and
Coordination, but More Remains to be Done' which was released on April
30, 2008.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
April 30, 2008:
The Honorable Daniel K. Akaka:
Chairman:
Committee on Veterans' Affairs:
United States Senate:
Subject: VA and DOD Health Care: Progress Made on Implementation of
2003 President's Task Force Recommendations on Collaboration and
Coordination, but More Remains to Be Done:
Dear Mr. Chairman:
Improving collaboration and health resource sharing between the
Department of Veterans Affairs (VA) and the Department of Defense (DOD)
has been the focus of numerous efforts by Congress and the executive
branch for more than two decades. In 1982, Congress passed the
Veterans' Administration and Department of Defense Health Resources
Sharing and Emergency Operations Act (Sharing Act), which authorized VA
and DOD health care facilities to partner and enter into sharing
agreements to buy, sell, and barter medical and support
services.[Footnote 1] Since then, Congress has passed additional
legislation to continue to promote VA and DOD health resource
sharing.[Footnote 2] However, in previous work we have pointed out
continuing barriers to such efforts, including incompatible computer
systems that affect the exchange of patient health information,
inconsistent reimbursement and budgeting policies, and burdensome
processes for approving agreements between the departments.[Footnote 3]
On May 28, 2001, the President established the 15-member President's
Task Force to Improve Health Care Delivery for Our Nation's Veterans.
The task force's mission was to identify ways to improve coordination
and sharing between VA and DOD in order to improve health care for
servicemembers and veterans.[Footnote 4] The task force reviewed
barriers and challenges in several areas related to coordination,
including leadership, transition to veteran status, and improving
quality of health care. In May 2003, it made recommendations to VA and
DOD to increase collaboration and coordination between the two
departments to improve health care delivery.[Footnote 5] The task force
also recommended that the administration take action through the
Department of Health and Human Services (HHS) to help improve VA and
DOD collaboration, and that Congress take additional action to improve
such collaboration. Other more recent task force and commission reports
have voiced similar concerns and identified more areas for improvement.
These reports include the 2007 Task Force on Returning Global War on
Terror Heroes report,[Footnote 6] the 2007 President's Commission on
Care for America's Returning Wounded Warriors "Dole-Shalala
report,"[Footnote 7] and the 2007 Veterans' Disability Benefits
Commission report.[Footnote 8]
You asked us to examine the status of VA and DOD's efforts in
implementing the 2003 task force recommendations. Specifically, this
report describes the extent to which VA and DOD have implemented the
recommendations of the 2003 President's Task Force to Improve Health
Care for Our Nation's Veterans related to collaboration and
coordination.
The scope of this report is the 20 recommendations in the first four
chapters of the task force's report, which focus on increased
collaboration and coordination.[Footnote 9] To describe the extent to
which VA and DOD have implemented the task force recommendations, we
collected information on the departments' related activities by
reviewing documents provided by VA and DOD--including the departments'
written responses to our questions, annual reports, and other
documents; interviewing department officials; reviewing related task
force and commission reports; and reviewing our prior work on related
subjects. We examined information provided by VA and DOD officials and
compared information provided by the departments with relevant findings
from our prior reports. Although some of the task force recommendations
had multiple parts, we considered each recommendation as a whole,
rather than addressing a recommendation's parts individually. A few
recommendations contained deadlines that have lapsed, and we have
described the departments' actions to date without consideration of
these deadlines. We conducted our work from July 2007 through April
2008 in accordance with generally accepted government auditing
standards.
In summary, we found that VA and DOD have made progress in implementing
the task force recommendations, but more remains to be done to fully
implement all task force recommendations. Seven of the recommendations
have been fully implemented and 11 have been partially implemented. We
could not determine the status of 1 because of insufficient
information, and 1 does not require VA or DOD action.
* Fully implemented. Four out of the seven recommendations we found to
be fully implemented have been carried out through the Joint Executive
Council (JEC), an interagency leadership committee of VA and DOD
officials.[Footnote 10] The JEC issues annual reports on its
activities, has developed joint health care outcome metrics, and has
identified functional areas to reengineer business processes and
information technology to enhance care, as recommended. It also
regularly uses civilian consultants in its collaborative efforts, as
recommended. In addition, the departments have fully implemented three
other task force recommendations that address expanding collaboration
to collect and maintain data on servicemembers' occupational exposure
and hazards; sharing routinely information on servicemembers'
assignment history, occupational exposures, and injuries; and
conducting continuous health surveillance and research on the long-term
health consequences of military service.
* Partially implemented. These 11 recommendations address a variety of
issues, such as developing interoperable electronic medical records,
implementing a mandatory single physical examination when a
servicemember is separating from military service, and integrating
pharmacy initiatives. The departments have made progress in
implementing these recommendations, but have more to do to fully
implement them.
* Unable to determine. As of April 2008, VA and DOD had not provided
sufficient information for us to determine the status of one
recommendation. The recommendation requires that the departments
address staffing shortfalls, develop consistent clinical scopes of
practice for nonphysician providers, and ensure interfacing
credentialing systems. We were not able to determine the status of this
recommendation because VA and DOD did not provide sufficient
information on their efforts to address staffing shortfalls and to
develop consistent clinical scopes of practice for nonphysician
providers.
* No action required. One recommendation requires that the
administration direct HHS to declare VA and DOD a single health care
system for purposes of facilitating the exchange of health information
in accordance with the Health Insurance Portability and Accountability
Act (HIPAA) Privacy Rule.[Footnote 11] According to VA, the departments
have sufficient authority for data sharing as permitted by HIPAA
without becoming one single entity.[Footnote 12] In addition, VA and
DOD have implemented a data-sharing memorandum of understanding (MOU)
that outlines agreed-upon authorities for sharing protected health
information as permitted by HIPAA.
See table 1 for the implementation status of the task force
recommendations. See enclosure I for a detailed description of the
recommendations, the implementation status, the actions taken by VA and
DOD, and the actions remaining to fully implement the task force
recommendations.
Table 1: Status of 2003 President's Task Force Recommendations Related
to VA and DOD Collaboration and Coordination:
Recommendation, by type and number: Reporting: 1.1;
Recommendation, by type and number: Reporting: Require the interagency
leadership committee to annually report to VA and DOD Secretaries on
task force recommendations and activities;
Status: Fully Implemented.
Recommendation, by type and number: Leadership, collaboration, and
oversight: 2.1;
Recommendation, by type and number: Leadership, collaboration, and
oversight: Broaden the interagency leadership committee charter beyond
health care and have the committee consider using civilian consultants
for collaboration;
Status: Fully Implemented.
Recommendation, by type and number: Leadership, collaboration, and
oversight: 2.2;
Recommendation, by type and number: Leadership, collaboration, and
oversight: Use a joint strategic planning and budgeting process;
Status: Partially Implemented.
Recommendation, by type and number: Leadership, collaboration, and
oversight: 2.3;
Recommendation, by type and number: Leadership, collaboration, and
oversight: Develop joint health care outcome metrics;
Status: Fully Implemented.
Recommendation, by type and number: Seamless transition to veteran
status: 3.1;
Recommendation, by type and number: Seamless transition to veteran
status: Seamless transition to veteran status: Develop interoperable
electronic medical records;
Status: Partially Implemented.
Recommendation, by type and number: Seamless transition to veteran
status: 3.2;
Recommendation, by type and number: Seamless transition to veteran
status: Require the administration to direct the Department of Health
and Human Services (HHS) to declare that VA and DOD are a single health
care system for Health Insurance Portability and Accountability Act
(HIPAA) purposes;
Status: No action needed.
Recommendation, by type and number: Seamless transition to veteran
status: 3.3;
Recommendation, by type and number: Seamless transition to veteran
status: Implement a mandatory single physical examination for
servicemembers separating from military service and electronic
transmission of separation information;
Status: Partially Implemented.
Recommendation, by type and number: Seamless transition to veteran
status: 3.4;
Recommendation, by type and number: Seamless transition to veteran
status: Facilitate a seamless transition to veteran status;
Status: Partially Implemented.
Recommendation, by type and number: Seamless transition to veteran
status: 3.5;
Recommendation, by type and number: Seamless transition to veteran
status: Collaborate on collecting and maintaining information on
servicemember exposure and hazards;
Status: Fully Implemented.
Recommendation, by type and number: Seamless transition to veteran
status: 3.6;
Recommendation, by type and number: Seamless transition to veteran
status: Share routinely information on servicemember assignment
history, exposure, and injuries;
Status: Fully Implemented.
Recommendation, by type and number: Seamless transition to veteran
status: 3.7;
Recommendation, by type and number: Seamless transition to veteran
status: Conduct surveillance and research on long-term health
consequences of military service;
Status: Fully Implemented.
Recommendation, by type and number: Removing barriers to collaboration:
4.1;
Recommendation, by type and number: Removing barriers to collaboration:
Revise health care system organizational structures to improve
coordination and enhance care;
Status: Partially Implemented.
Recommendation, by type and number: Removing barriers to collaboration:
4.2;
Recommendation, by type and number: Removing barriers to collaboration:
Enhance local and regional authority, accountability, and incentives
for collaborative health care efforts;
Status: Partially Implemented.
Recommendation, by type and number: Removing barriers to collaboration:
4.3;
Recommendation, by type and number: Removing barriers to collaboration:
Integrate pharmacy initiatives;
Status: Partially Implemented.
Recommendation, by type and number: Removing barriers to collaboration:
4.4;
Recommendation, by type and number: Removing barriers to collaboration:
Allow shared patients to obtain prescriptions at both VA and DOD
pharmacies;
Status: Partially Implemented.
Recommendation, by type and number: Removing barriers to collaboration:
4.5;
Recommendation, by type and number: Removing barriers to collaboration:
Standardize medical supplies and equipment identification for joint
acquisition;
Status: Partially Implemented.
Recommendation, by type and number: Removing barriers to collaboration:
4.6;
Recommendation, by type and number: Removing barriers to collaboration:
Identify functional areas where the departments have similar
requirements for reengineering business processes and information
technology to enhance care;
Status: Fully Implemented.
Recommendation, by type and number: Removing barriers to collaboration:
4.7;
Recommendation, by type and number: Removing barriers to collaboration:
Implement facility lifecycle management practices;
Status: Partially Implemented.
Recommendation, by type and number: Removing barriers to collaboration:
4.8;
Recommendation, by type and number: Removing barriers to collaboration:
Develop joint policies and lessons learned on joint ventures;
Status: Partially Implemented.
Recommendation, by type and number: Removing barriers to collaboration:
4.9;
Recommendation, by type and number: Removing barriers to collaboration:
Address staffing shortfalls, develop consistent clinical scopes of
practice for nonphysician providers, and ensure interfacing
credentialing systems;
Status: Unable to determine.
Source: GAO analysis of VA and DOD information and President's task
force report.
[End of table]
We provided draft copies of this report to VA and DOD for review and
comment. VA provided written comments and technical comments, and
agreed with our findings. DOD provided written comments and agreed with
our findings provided that we incorporate technical comments that it
provided. We incorporated the agencies' technical comments as
appropriate, including comments that changed the implementation status
of the task force recommendations, updated information, or provided a
clearer understanding of the actions VA and DOD have taken or actions
that remain to be taken. VA and DOD comments are reprinted in
enclosures II and III, respectively.
We are sending copies of this report to the Secretary of Veterans
Affairs and the Secretary of Defense and appropriate congressional
committees. 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 [hyperlink, http://www.gao.gov].
If you or your staff have questions about this report, please contact
me at (206) 287-4860 or williamsonr@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff members who made key
contributions to this report are listed in enclosure IV.
Sincerely yours,
Randall B. Williamson:
Director, Health Care:
Enclosures - 4:
Enclosure I:
VA and DOD Actions Taken and Actions Remaining to Fully Implement the
2003 President's Task Force Recommendations Related to Collaboration
and Coordination:
Table 2:
Recommendation, by type and number: Reporting: 1.1: The interagency
leadership committee should, on an annual basis, report to the
Secretaries on the status of implementing its collaboration and sharing
initiatives and the recommendations in this Final Report, together with
any other matters that the committee deems appropriate. Within 60 days
after receipt, the Secretaries shall transmit the report, together with
any related comments, to the President;
Status: Fully Implemented;
Action taken: The VA/ DOD Joint Executive Council (JEC), first
established as the interagency leadership committee in 2002,[A] issues
an annual report describing progress on VA and DOD collaborative
efforts. According to DOD, the JEC annual report is consistent with the
President's task force recommendations in that it addresses the same
key issues;
Action remaining: None.
Recommendation, by type and number: Leadership, collaboration, and
oversight: 2.1: Congress should amend the fiscal year 2003 National
Defense Authorization Act to create a broader charter beyond health
care for the interagency leadership committee. Additionally,
consideration should be given to using civilian experts as consultants
to the committee to bring in new perspectives regarding collaboration
and sharing;
Status: Fully Implemented;
Action taken: Congress expanded the scope of the JEC to benefits and
services, generally, through the National Defense Authorization Act
(NDAA) for Fiscal Year 2004.[B] VA and DOD have used civilian experts
as consultants in many areas--for example, a JEC working group
consulted with a civilian company on information systems and
technology. VA and DOD officials also told us that they will be using
civilian subject matter experts to assist each of the JEC working
groups in developing performance measures and targets for the Joint
Strategic Plan (JSP);
Action remaining: None.
Recommendation, by type and number: Leadership, collaboration, and
oversight: 2.2: The departments should consistently utilize a joint
strategic planning and budgeting process for collaboration and sharing
to institutionalize the development of joint objectives, strategies,
and best practices, along with accountability for outcomes;
Status: Partially Implemented;
Action taken: The JEC has developed a new JSP each year since 2003. The
JSP is reviewed, updated as necessary, and included in the annual JEC
report. According to DOD, the JSP outlines actionable objectives,
assigns accountability, and establishes performance targets. In
addition, VA told us that the departments recently held a joint budget
review under the auspices of the Senior Oversight Committee (SOC) in
order to determine budgetary needs associated with recommendations and
statutory requirements related to collaboration activities. Further,
according to VA, the departments will periodically review joint
collaboration requirements and associated budgets in order to ensure
recommendations and statutory requirements are met;
Action remaining: VA and DOD are not utilizing a joint budgeting
process, as recommended by the task force. According to the
departments, they do not have legal authority to submit joint budgets.
Instead, VA and DOD have begun other efforts to align their health care
budgets that could facilitate fully implementing this recommendation.
Recommendation, by type and number: Leadership, collaboration, and
oversight: 2.3: The departments should jointly develop metrics (with
indicated accountability) that measure health care outcomes related to
access, quality, and cost as well as progress toward objectives for
collaboration, sharing and desired outcomes. In the annual report
prescribed in recommendation 1.1, the interagency leadership committee
should include these results and discuss the coming year's goals;
Status: Fully Implemented;
Action taken: VA and DOD have jointly developed metrics to measure
health care outcomes related to access, quality, and cost, as well as
progress toward objectives for collaboration, sharing, and desired
outcomes. Such metrics are included in the JSP, which consists of six
strategic goals accompanied by performance expectations, measurements,
and timelines.[C] Progress is reported in the JEC annual report, and
according to the departments, also at bimonthly Health Executive
Council (HEC) and Benefits Executive Council meetings and quarterly JEC
meetings;
Action remaining: None.
Recommendation, by type and number: Seamless transition to veteran
status: 3.1: VA and DOD should develop and deploy by fiscal year 2005
electronic medical records that are interoperable, bidirectional, and
standards-based;
Status: Partially Implemented;
Action taken: Outpatient pharmacy and drug allergy data, but not other
health care data, are currently electronic, interoperable,
bidirectional, and standards-based. This computable information is
exchanged for shared patients at seven sites via the interface between
the DOD Clinical Data Repository and the VA Health Data Repository
known as CHDR. VA and DOD are also sharing health data through other
initiatives in which the data are not computable. For example, the
Bidirectional Health Information Exchange (BHIE), now operational at
all VA and DOD sites, does not enable the exchange of data but allows
clinicians in both departments to view selected medical data on screen
in real time. With BHIE, the clinicians can view outpatient pharmacy
data, allergy information, radiology reports, surgical pathology
reports, microbiology results, cytology reports, laboratory orders,
chemistry and hematology reports, and at some sites, inpatient
discharge summaries and/or emergency room notes. The departments have
teamed to develop the Joint DOD/VA Information Interoperability Plan,
targeted for approval in August 2008, to guide the development and
implementation of an interoperable, bidirectional, and standards based
electronic health record capability for military and veteran
beneficiaries;
Action remaining: The departments are not able to exchange all health
care data as computable medical records that are interoperable,
bidirectional, and standards-based, as recommended by the task force.
Further, they have not developed a comprehensive project plan with a
completion date, which would guide their efforts until the goal of the
comprehensive, seamless exchange of electronic medical records is
achieved.[D,E].
Recommendation, by type and number: Seamless transition to veteran
status: 3.2: The administration should direct HHS [the Department of
Health and Human Services] to declare the two departments to be a
single health care system for purposes of implementing HIPAA [the
Health Insurance Portability and Accountability Act] regulations;
Status: No action needed;
Action taken: According to VA, the departments have sufficient
authority for data sharing as permitted by HIPAA without becoming a
single entity.[F] In addition, VA and DOD have implemented a data-
sharing memorandum of understanding (MOU) that outlines agreed-upon
authorities for sharing protected health information as permitted by
HIPAA. VA and DOD officials also told us that the departments are
sharing data at an unprecedented level and are continuing to expand
shared access to data;
Action remaining: None.
Recommendation, by type and number: Seamless transition to veteran
status: 3.3: The departments should implement by fiscal year 2005 a
mandatory single separation physical as a prerequisite of promptly
completing the military separation process. Upon separation, DOD should
transmit an electronic DD214 [military discharge document] to VA;
Status: Partially Implemented;
Action taken: VA and DOD have established procedures for single
separation physical examinations and methods to monitor their conduct.
However, as we noted in a November 2004 report, the agencies face
challenges in expanding use of single separation physicals, such as
lack of requirements for separation physical examinations in all
services and lack of resources.[G] In comments on our November 2004
report, DOD identified problems with DOD- VA electronic data
interchange as a barrier to better monitoring of single separation
physicals. Recently enacted legislation mandates joint DOD-VA
processes, procedures, and standards for transition of recovering
servicemembers from DOD to VA, including a process for single
separation physical examinations.h; DOD and VA are piloting a joint
disability evaluation process, including a single physical examination.
For pilot participants, this examination is also intended to serve as
the single separation examination; According to DOD officials, the
Defense Integrated Military Human Resources System (DIMHRS) is being
developed to provide the electronic, computable interface between VA
and DOD systems for transmittal and use of an electronic DD214. As of
February 2008, DIMHRS has not been deployed. Plans are for the Army to
start using DIMHRS in late 2008. The Air Force is planning to begin
using DIMHRS in early 2009. The Navy and Marine Corps will start using
DIMHRS at a date to be determined;
Action remaining: VA and DOD have not fully implemented a mandatory
single separation physical examination for all servicemembers
completing their military service, which would be facilitated by
developing the mandated transition process; The departments have also
not fully implemented a process for transmitting computable electronic
DD214s from DOD to VA, as DOD has not completed the development of
DIMHRS to transmit the information electronically.
Recommendation, by type and number: Seamless transition to veteran
status: 3.4: VA and DOD should expand the one-stop shopping process to
facilitate a more effective seamless transition to veteran status. This
process should provide, at a minimum: (1) a standard discharge
examination suitable to document conditions that might indicate a
compensable condition; (2) full outreach; (3) claimant counseling; (4)
when appropriate, referral for a compensation and pension examination
and follow-up claims adjudication and rating;
Status: Partially Implemented;
Action taken: For a discussion of the single separation physical
examination issue, see recommendation 3.3; Under the Transition
Assistance Program and Disabled Transition Assistance Program, VA
provides job-search, employment, education, and VA benefits
information. In fiscal year 2007, VA conducted over 8,000 briefings to
almost 300,000 servicemembers; According to VA, the department has
stationed personnel at major military treatment facilities (MTF) to
help wounded servicemembers as they transition from military to
civilian life. These include personnel to help servicemembers apply for
VA disability benefits. Under the DOD-VA disability evaluation pilot,
DOD Physical Evaluation Board Liaison Officers and VA Military Service
Coordinators are tasked to assist servicemembers during the disability
evaluation process. In addition, VA has hired and trained eight Federal
Recovery Coordinators, as recommended by the Dole-Shalala Commission,
to help assist wounded, ill, and injured servicemembers at three DOD
medical facilities; Under its Benefits Delivery at Discharge (BDD)
program, VA takes disability claims from servicemembers prior to
discharge and begins to process them. VA and DOD have agreements to
take such claims at about 140 sites. According to VA, of all original
disability compensation claims filed within 1 year of discharge, 53
percent were filed prior to discharge at BDD sites. Under the DOD-VA
disability evaluation pilot, VA is taking claims from servicemembers
early in the DOD evaluation process;
Action remaining: VA and DOD have not expanded the one-stop shopping
process to create a seamless transition to veteran status for all
veterans, as recommended by the task force; The streamlined process
currently being piloted has the potential to expedite VA claims
processing, with VA taking claims and making disability rating
decisions for some servicemembers prior to discharge.[I] While DOD and
VA plan to expand the pilot beyond its current sites, they have not
developed expansion criteria. Also, their evaluation plans do not have
some key elements, including an approach for measuring pilot
performance against the current process.
Recommendation, by type and number: Seamless transition to veteran
status: 3.5: VA and DOD should expand their collaboration in order to
identify, collect, and maintain the specific data needed by both
departments to recognize, treat, and prevent illness and injury
resulting from occupational exposures and hazards experienced while
serving in the Armed Forces; and to conduct epidemiological studies to
understand the consequences of such events;
Status: Fully Implemented;
Action taken: DOD collects pre-and post-deployment health assessments
from each servicemember on overall physical and mental health,
injuries, and possible environmental or occupational exposures. DOD
routinely shares this information with VA for the diagnosis and care of
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
servicemembers. DOD also collects and monitors air, soil, and water
samples where troops are deployed. These and other shared information
are used for cooperative medical care and research efforts. DOD has
made progress in improving collection and reporting of health
information as part of its health quality assurance program, including
standardizing, documenting, and auditing its efforts; (See action taken
on recommendation 3.7 for information on epidemiological studies.);
Action remaining: None.
Recommendation, by type and number: Seamless transition to veteran
status: 3.6: By fiscal year 2004, VA and DOD should initiate a process
for routine sharing of each servicemember's assignment history,
location, occupational exposure, and injuries information;
Status: Fully Implemented;
Action taken: Since 2005, DOD has sent VA monthly electronic health
assessment and assignment information on deactivated or separated
servicemembers. The assessment data include assignment history,
location, occupational exposure, and injuries. In addition, DOD
routinely sends VA data on servicemembers deployed to OEF/OIF and on
those who have entered DOD's physical evaluation process, which is used
to determine disability status. The Information Management/Information
Technology Working Group of the HEC continues efforts to improve
medical data sharing;
Action remaining: None.
Recommendation, by type and number: Seamless transition to veteran
status: 3.7: The department should: (1) add an ex officio member from
VA to the Armed Forces Epidemiological Board and to the DOD Safety and
Occupational Health Committee; (2) implement continuous health
surveillance and research programs to identify the long-term health
consequences of military service in high-risk occupations, settings, or
events; and (3) jointly issue an annual report on force health
protection, and make it available to the public;
Status: Fully Implemented;
Action taken: An ex officio member from VA was added to the Defense
Health Board (formerly the Armed Forces Epidemiological Board) and the
DOD Safety and Occupational Health Committee; VA and DOD conduct health
surveillance and research using data collected on high-risk
occupations, settings, and events through pre-and post-deployment
health assessments. Data collected by DOD are also used to monitor air,
soil, and water samples from each deployment location for health
surveillance and research. VA and DOD, along with HHS, funded medical
surveillance initiatives and long-term research projects related to
OIF/OEF deployment and illnesses in veterans of the 1991 Gulf War. For
example, VA and DOD collaborated on epidemiological projects related to
exposure to depleted uranium and chemical warfare agents. VA and DOD
also developed an inventory of 432 medical research projects on the
health of deployed servicemembers and veterans that is updated
annually; VA and DOD officials told us that the Deployment Health
section of the JEC annual report, available online, serves as the force
health protection report;
Action remaining: None.
Recommendation, by type and number: Removing barriers to collaboration:
4.1: The Secretaries of Veterans Affairs and Defense should revise
their health care organizational structures in order to provide more
effective and coordinated management of their individual health care
systems, enhance overall health care outcomes, and improve the
structural congruence between the two departments;
Status: Partially Implemented;
Action taken: VA and DOD officials told us that the JEC and the SOC
provide more effective and coordinated management of the departments'
individual health care systems and that they do not believe revising
health care organizational structures would necessarily improve
coordination. The SOC was established in 2007 to bring high-level
attention to addressing problems with the care and services for
servicemembers returning from OEF/OIF.[J] According to VA and DOD
officials, the SOC is expected to disband by the end of 2008 or early
2009, and responsibilities for VA and DOD collaboration will shift to
the JEC;
Action remaining: VA and DOD have not revised their health care
organizational structures to improve structural congruence between the
two departments. The departments are relying on the JEC and the SOC to
coordinate efforts between their individual health care systems.
Recommendation, by type and number: Removing barriers to collaboration:
4.2: The Secretaries of Veterans Affairs and Defense, based on the
recommendations of the interagency leadership committee, should provide
significantly enhanced authority, accountability, and incentives to
health care managers at the local and regional levels in order to
enhance standardized and collaborative activities that improve health
care delivery and control costs;
Status: Partially Implemented;
Action taken: The departments provided leadership and authority for
local and regional health care managers to enhance collaboration,
improve health care delivery, and control costs. VA states that it has
provided accountability and incentives for local and regional managers
through performance plans and appraisals and scoring factors for shared
capital investment projects. DOD states that it has also eliminated
some financial disincentives for collaboration for local MTF managers.
In addition, the departments had 504 direct sharing agreements covering
2,090 unique services in fiscal year 2006; The departments have also
implemented the ongoing DOD-VA Health Care Sharing Joint Incentive Fund
(JIF), to identify, provide incentives to, implement, fund, and
evaluate creative coordination and sharing initiatives at the facility,
regional, and national levels.[K] Federal law requires that VA and DOD
each contribute a minimum of $15 million ($30 million total) into this
fund annually. With these funds, VA and DOD had approved and funded 47
projects as of February 2007. In addition, 7 demonstration projects
were implemented to evaluate the success of joint projects and share
lessons learned with other sites;
Action remaining: VA and DOD have not demonstrated how they have
provided either accountability or system-wide incentives for local and
regional health care managers in support of collaboration, as
recommended by the task force.
Recommendation, by type and number: Removing barriers to collaboration:
4.3: VA and DOD should integrate clinical pharmacy initiatives through
the coordinated development of: (1) a national joint core formulary;
and (2) a single, common clinical data screening tool by fiscal year
2005 that ensures reliable, electronic access to complete
pharmaceutical profiles for VA/DOD dual users across both systems;
Status: Partially Implemented;
Action taken: VA and DOD do not accept that a national joint core
formulary is needed. As an alternative, they had awarded 77 joint
national contracts for medications as of the first three quarters of
fiscal year 2007 and continue to evaluate 24 additional drugs for joint
contracts; VA and DOD's CHDR allows real-time bidirectional exchange of
electronic pharmacy and drug allergy data for shared patients at seven
sites. This enables them to share a common pharmaceutical clinical data
screening tool, including computable data that allow both departments'
systems to screen for potential drug interactions and allergies. VA and
DOD officials plan to have CHDR available at all sites by summer 2008;
The Pharmacy Re-engineering Project is under development and a joint
team is working to improve the percentage of pharmacy data that can be
exchanged for shared patients. Both departments have adopted a standard
for exchanging medication-allergy data;
Action remaining: The DOD Uniform Formulary, created under regulations
issued pursuant to the DOD pharmacy statute,[L] prevents DOD from
participating in a joint formulary with VA, as recommended by the task
force. As an alternative, the departments will continue to collaborate
on formulary decisions and expand joint pharmaceutical purchases; The
departments have not yet fully implemented a clinical data screening
tool and electronic pharmaceutical profiles for all shared patients, as
recommended by the task force. To do so, VA and DOD are continuing
their efforts to expand CHDR to all sites.[M].
Recommendation, by type and number: Removing barriers to collaboration:
4.4: VA and DOD should collaborate on policy and program changes,
through local sharing arrangements, which would permit prescriptions
written by either VA or MTF providers to be filled for dual users by
the other department's pharmacies; Status: Partially Implemented;
Action taken: According to the departments, DOD is able to fill
prescriptions from any physician, including VA providers, for all
shared patients at MTFs, retail network pharmacies, or TRICARE mail-
order pharmacy programs. VA will fill prescriptions for shared patients
who are using VA providers, and may fill prescriptions written by non-
VA providers in rare circumstances. In some locations, VA and DOD have
local sharing agreements allowing prescriptions for shared patients to
be filled at VA pharmacies;
Action remaining: VA does not always fill prescriptions for shared
patients, as recommended by the task force, because its regulations do
not permit VA to do so.[N].
Recommendation, by type and number: Removing barriers to collaboration:
4.5: VA and DOD should work with industry to establish a uniform
methodology for medical supplies and equipment identification and
standardization and to facilitate additional joint contracting
initiatives. VA and DOD should identify opportunities for joint
acquisitions in all areas of products and services;
Status: Partially Implemented;
Action taken: VA and DOD have worked with industry to standardize
identification data for medical supplies and equipment through the HEC,
and according to DOD, the departments will continue to work with
industry and follow industry recommendations. For example, initial
results released in September 2007 for a health care industry pilot
demonstrated that the Global Data Synchronization Network (GDSN) has
the potential to work for the health care industry, and industry
leaders have recommended the GDSN as an industry-wide information
sharing solution. In addition, according to VA, the departments have
developed their own joint Medical/Surgical Product Data Bank as part of
their JIF-funded joint data synchronization project. Also through the
HEC, VA and DOD have rechartered the Acquisition and Medical Material
Working Group to identify more ways to collaboratively acquire health
care commodities and services;
Action remaining: VA and DOD have not fully established a uniform
methodology for medical supplies and equipment identification and
standardization, as recommended by the task force. Their continued work
with industry could facilitate their efforts on this recommendation; In
addition, VA and DOD have not demonstrated that they have identified
opportunities for joint acquisitions in all areas of products and
services, as recommended by the task force, though the rechartered
working group may have the potential to do so.
Recommendation, by type and number: Removing barriers to collaboration:
4.6: The interagency leadership committee should identify those
functional areas where the departments have similar information
requirements so that they can work together to reengineer business
processes and information technology in order to enhance
interoperability and efficiency;
Status: Fully Implemented; Action taken: VA and DOD have identified
functional areas and included them in the JSP. For example, the fiscal
year 2004 JSP states as part of Goal 2 that VA and DOD will collaborate
on internal and external reporting systems for patient safety. Goals 3,
4, and 5 of the fiscal year 2004 JSP present information about goals
directed to the seamless coordination of benefits, integrated
information sharing, and efficiency of operations, respectively.
Functions identified within these goals include health information
technology; health clinical data sharing, such as in- patient
assessments; imaging; laboratory data sharing; and delivery of
benefits;
Action remaining: None.
Recommendation, by type and number: Removing barriers to collaboration:
4.7: VA and DOD should implement facility lifecycle management
practices on an enterprise-wide basis. This should be accomplished by
aligning business rules, eliminating statutory barriers, and adopting
best practices;
Status: Partially Implemented;
Action taken: In 2003, the JEC established the VA-DOD Construction
Planning Committee (CPC) that provides a formalized structure to
facilitate collaboration and coordination in achieving an integrated
approach to capital coordination that considers both short-term and
long-term strategic capital issues. The 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 the JEC structure. Under the CPC framework, collaborative
efforts have been initiated for aligning business rules, eliminating
statutory barriers, and identifying best practices for VA and DOD; For
example, according to VA and DOD, the two departments have begun to
share planning documents for major construction projects to determine
those with collaborative potential and explore methods to ensure high
potential projects are fully considered and included in both
departments' capital investment processes. In addition, DOD adopted
VA's capital investment methodology and adapted its analytical process
for evaluating, prioritizing, and ranking major construction projects.
VA, in turn, adopted DOD's facilities sustainment model to standardize
the process for estimating funding levels for sustaining its capital
assets portfolio. VA and DOD now use the same planning platform to
develop projects, thus making future collaborative opportunities easier
to define requirements;
Action remaining: VA and DOD have not demonstrated that they have
implemented facility lifecycle management practices on an enterprise-
wide basis, as recommended by the task force.
Recommendation, by type and number: Removing barriers to collaboration:
4.8: VA and DOD should declare that joint ventures are integral to the
standard operations of both departments. Through the interagency
leadership committee, the departments should articulate policy
requiring that: (1) all major initiatives of each department be
designed and tested for effectiveness and suitability in joint venture
sites; (2) lessons learned from successful joint ventures be shared
with other joint venture sites and also throughout the health care
delivery systems of the two departments; and (3) all proposed VA and
DOD facility construction within a geographic area be evaluated as a
potential joint venture;
Status: Partially Implemented;
Action taken: In 2005, DOD issued a policy directive that assigned
responsibilities and prescribed procedures for the development and
operation of DOD-VA health care resource sharing agreements. The
directive also defined joint ventures and discussed departmental policy
on joint ventures, among other things; In 2005, 2006, and 2007, VA and
DOD sponsored annual conferences to bring together leadership from all
joint venture sites to share lessons learned; In 2006, VA established a
Joint Venture Proposals Working Group to develop criteria for
evaluating joint venture proposals at the department level and a
communications strategy for use during joint venture negotiations. VA
issued the criteria and communications strategy in a handbook in
November 2007. The handbook details departmental policy on joint
ventures, defines joint ventures, and identifies the process for
reviewing and approving joint venture proposals, among other things; VA
and DOD have also established a Joint Market Opportunities Work Group
to examine the existing VA-DOD joint ventures and the potential for
additional joint ventures. In the first phase of its review, the
working group studied all eight existing VA-DOD joint venture sites to
identify best practices, lessons learned, and challenges. The working
group reported the findings from the first phase of its review to the
JEC in January 2008. In the second phase of its review, the working
group plans to assess potential opportunities for colocation and
comanagement of VA-DOD facilities. The working group has identified
some locations to study and expects to report its findings from the
second phase to the JEC in July 2008;
Action remaining: VA and DOD have not fully developed and implemented
joint policies that state that joint ventures are integral to the
standard operations of both departments or ensure that all major
initiatives of each department are designed and tested for the
effectiveness and suitability in joint venture sites, as recommended by
the task force.
Recommendation, by type and number: Removing barriers to collaboration:
4.9: VA and DOD should work together to identify and address staffing
shortfalls, develop consistent clinical scopes of practice for
nonphysician providers, and ensure that their provider credentialing
systems interface with each other;
Status: Unable to determine;
Action taken: VA and DOD piloted a credentialing interface that was
shown to be technically feasible, but both departments told us that the
time and money required to support and maintain a mutual electronic
credentialing system was not warranted as the number of credentialed
providers working in both VA and DOD facilities is too small to justify
the expenditure. The interface is no longer in use, but according to
VA, it may be reestablished if it is needed in the future;
Action remaining: We are unable to determine what remains to be done to
fully implement this recommendation, because VA and DOD have not
provided sufficient information to determine the status of their
progress on addressing staffing shortfalls or on developing consistent
clinical scopes of practice for nonphysician providers.
Source: GAO analysis of VA and DOD information and President's task
force report.
[A] In accordance with the Bob Stump National Defense Authorization Act
for Fiscal Year 2003, Pub. L. No. 107-314, § 712(a), 116 Stat. 2590.
The JEC was originally called the DOD-VA Health Executive Committee.
[B] Pub. L. No. 108-136, § 583, 117 Stat. 1392, 1490 (2003) (codified
as amended at 38 U.S.C. § 320).
[C] The six strategic goals in the JSP are related to leadership,
commitment, and accountability; high-quality health care; seamless
coordination of benefits; integrated information sharing; efficiency of
operations; and joint medical contingency/readiness capabilities.
[D] See GAO, Information Technology: VA and DOD Are Making Progress in
Sharing Medical Information, but Are Far from Comprehensive Electronic
Medical Records, GAO-07-852T (Washington, D.C.: May 8, 2007).
[E] See GAO, Information Technology: VA and DOD Continue to Expand
Sharing of Medical Information, but Still Lack Comprehensive Electronic
Medical Records, GAO-08-207T (Washington, D.C.: Oct. 24, 2007).
[F] The HIPAA Privacy Rule permits the exchange of health care
information between VA-and DOD-covered entities for a number of
purposes, including to provide medical treatment, to make payments for
health care, and to make VA benefit determinations upon servicemembers'
discharge or separation from the armed forces. See 45 C.F.R. §§
164.506, 164.512(k) (2007).
[G] See GAO, VA and DOD Health Care: Efforts to Coordinate a Single
Physical Exam Process for Servicemembers Leaving the Military, GAO-05-
64 (Washington, D.C.: Nov. 12, 2004).
[H] NDAA for Fiscal Year 2008, Pub. L. No. 110-181, § 1614, 122 Stat.
3, 443-46.
[I] See GAO, DOD and VA: Preliminary Observations on Efforts to Improve
Care Management and Disability Evaluations for Servicemembers, GAO-08-
514T (Washington, D.C.: Feb. 27, 2008).
[J] To conduct its work, the SOC established work groups that focused
on specific areas, including case management; disability evaluation
systems; traumatic brain injury; psychological health, including post-
traumatic stress disorder; and data sharing between VA and DOD.
[K] In accordance with the Bob Stump National Defense Authorization Act
for Fiscal Year 2003, Pub. L. No. 107-314, § 721, 116 Stat. 2458, 2589-
2595 (2002) (codified as amended at 38 U.S.C. § 8111).
[L] 10 U.S.C. § 1074g.
[M] See GAO, DOD and VA Outpatient Pharmacy Data: Computable Data Are
Exchanged for Some Shared Patients, but Additional Steps Could
Facilitate Exchanging These Data for All Shared Patients, GAO-07-554R
(Washington, D.C.: Apr. 30, 2007).
[N] 38 C.F.R. § 17.96.
[End of table]
[End of section]
Enclosure II: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
April 14, 2008:
Mr. Randall B. Williamson:
Acting Director, Health Care:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's draft report, "VA AND DOD HEALTH CARE: Progress
Made on Implementation of 2003 President's Task Force Recommendations
on Collaboration and Coordination, but More Remains to Be Done (GAO-08-
495R)."
The report provides specific recommendations in areas where VA is
continuing to work with the Department of Defense (DoD) to develop new
strategies to assist in improving coordination and sharing between VA
and DoD and improving health care, services and benefits for
servicemembers and veterans.
VA agrees with your findings and provides updated detailed information
in the enclosure.
Sincerely yours,
Signed by:
James B. Peake, M.D.:
Enclosure:
[End of section]
Enclosure III: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
1200 Defense Pentagon:
Washington, DC 20301-1200:
Health Affairs:
April 11, 2008:
Randall B Williamson:
Acting Director, Health Care:
U.S. Government Accountability Office:
441 G Street, N.W.:
Washington, DC 20548
Dear Mr. Williamson:
This is the Department of Defense (DoD) response to the GAO draft
report, "VA DoD Health Care: Progress Made on Implementation of 2003
President's Task Force Recommendations on Collaboration, But More
Remains to Be Done," dated March 26, 2008 (GAO Code 290646/GAO-08-
495R)." The draft report examines very important aspects of our joint
efforts to implement the numerous recommendations for improving the way
the Departments of Defense and Veterans Affairs collaborate to deliver
health care services to our Nation's veterans.
I concur with the draft report's findings and conclusion provided that
the attached technical comments are incorporated into the final report.
DoD was and continues to be highly appreciative of the myriad
recommendations to improve the manner in which we work with the
Department of Veterans Affairs to provide benefits and services to the
brave men and women and their families who serve our country.
Again, thank you for the opportunity to provide these comments. My
points of contact for additional information are Mr. Ken Cox
(Functional) at (703) 681-4299 and Mr. Gunther Zimmerman (Audit
Liaison) at (703) 681-3492.
Sincerely,
Signed by:
S. Ward Casscells, MD:
Enclosure:
As stated:
[End of section]
Enclosure IV:
GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall Williamson, (206) 287-4860 or williamsonr@gao.gov:
Acknowledgments:
In addition to the contact named above, James C. Musselwhite, Jr.,
Assistant Director; Kye Briesath; Vashun Cole; Julie L. Thomas; Timothy
Walker; Greg Whitney; and Robert L. Williams, Jr. made major
contributions to this report.
[End of section]
Related GAO Products:
VA Health Care: Additional Efforts to Better Assess Joint Ventures
Needed. GAO-08-399. Washington, D.C.: March 28, 2008.
DOD and VA: Preliminary Observations on Efforts to Improve Care
Management and Disability Evaluations for Servicemembers. GAO-08-514T.
Washington, D.C.: February 27, 2008.
Information Technology: VA and DOD Continue to Expand Sharing of
Medical Information, but Still Lack Comprehensive Electronic Medical
Records. GAO-08-207T. Washington, D.C.: October 24, 2007.
DOD and VA: Preliminary Observations on Efforts to Improve Health Care
and Disability Evaluations for Returning Servicemembers. GAO-07-1256T.
Washington, D.C.: September 26, 2007.
GAO Findings and Recommendations Regarding DOD and VA Disability
Systems. GAO-07-906R. Washington, D.C.: May 25, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Are Far from Comprehensive Electronic Medical
Records. GAO-07-852T. Washington, D.C.: May 8, 2007.
DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for
Some Shared Patients, but Additional Steps Could Facilitate Exchanging
These Data for All Shared Patients. GAO-07-554R. Washington, D.C.:
April 30, 2007.
VA and DOD Health Care: Opportunities to Maximize Resource Sharing
Remain. GAO-06-315. Washington, D.C.: March 20, 2006.
Results-Oriented Government: Practices That Can Help Enhance and
Sustain Collaboration among Federal Agencies. GAO-06-15. Washington,
D.C.: October 21, 2005.
Defense Health Care: Improvements Needed in Occupational and
Environmental Health Surveillance during Deployments to Address
Immediate and Long-term Health Issues. GAO-05-632. Washington, D.C.:
July 14, 2005.
VA and DOD Health Care: Efforts to Coordinate a Single Physical Exam
Process for Servicemembers Leaving the Military. GAO-05-64. Washington,
D.C.: November 12, 2004.
Department of Veterans Affairs: Federal Gulf War Illnesses Research
Strategy Needs Reassessment. GAO-04-767. Washington, D.C.: June 1,
2004.
[End of section]
Footnotes:
[1] Pub. L. No. 97-174, 96 Stat. 70 (1982); Senate Report 97-137.
Before the Sharing Act was passed in 1982, VA and DOD health care
facilities--many of which were in close or joint locations--operated
virtually independently of each other.
[2] See the Bob Stump National Defense Authorization Act for Fiscal
Year 2003 under which VA and DOD were required to develop a joint
strategic plan and incorporate the joint goals and strategies into each
department's strategic and performance plans. Pub. L. No. 107-314, §
721, 116 Stat. 2458, 2589-2595 (2002) (codified as amended at 38 U.S.C.
§ 8111).
[3] See Related GAO Products at the end of this report.
[4] Exec. Order No. 13,214, 66 Fed. Reg. 29,447 (May 31, 2001).
[5] President's Task Force to Improve Health Care Delivery for Our
Nation's Veterans (May 26, 2003).
[6] Task Force on Returning Global War on Terror Heroes (Washington,
D.C.: Apr. 19, 2007).
[7] Serve, Support, Simplify: Report of the President's Commission on
Care for America's Returning Wounded Warriors (July 30, 2007).
[8] Honoring the Call to Duty: Veterans' Disability Benefits in the
21st Century, Veterans' Disability Benefits Commission (Washington,
D.C.: Oct. 3, 2007).
[9] The remaining chapter, "Timely Access to Health Services and the
Mismatch between Demand and Funding," includes three recommendations
that are not included in our scope. The recommendations in this chapter
focus on congressional appropriations and related actions rather than
department activities.
[10] The JEC is co-chaired by the Deputy Secretary of Veterans Affairs
and the Under Secretary of Defense for Personnel and Readiness, and the
membership--which is selected by the co-chairs--consists of senior
executives from both VA and DOD.
[11] The Privacy Rule applies to covered entities and specifies how
individually identifiable health data may be used and disclosed by
covered entities. See 45 C.F.R. §§ 164.500(a), et seq. (2007). Covered
entities are defined in the Privacy Rule as health plans,
clearinghouses, and certain health care providers. Both the DOD and VA
health care systems are covered entities. See 45 C.F.R. § 160.103
(2007). All covered entities had to comply with the Privacy Rule by
April 14, 2003, with the exception of small health plans.
[12] The HIPAA Privacy Rule permits the exchange of health care
information between VA-and DOD-covered entities for a number of
purposes, including to provide medical treatment, to make payments for
health care, and to make VA benefit determinations upon servicemembers'
discharge or separation from the armed forces. See 45 C.F.R. §§
164.506, 164.512(k) (2007).
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office:
441 G Street NW, Room LM:
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
