VA Health Care:

Additional Efforts to Better Assess Joint Ventures Needed

GAO-08-399: Published: Mar 28, 2008. Publicly Released: Mar 28, 2008.

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The Department of Veterans Affairs (VA) and the Department of Defense (DOD) have a long history of partnering to achieve more cost-effective use of health care resources. Their partnerships have evolved to include joint ventures--joint efforts to construct or share medical facilities. VA has maintained eight joint ventures with DOD across the country. VA has also developed partnerships, or affiliations, with university medical schools to obtain health care services for veterans and provide training to medical residents. VA has not entered into a joint venture with an academic affiliate to date. However, several proposals for such joint ventures have surfaced in the last decade. This congressionally requested report discusses the (1) potential benefits and concerns associated with joint ventures and the extent to which they are documented and measured, (2) lessons learned from existing and proposed VA joint ventures, and (3) steps VA has taken to evaluate proposed joint ventures. To address these issues, GAO conducted site visits to and interviews with officials from all existing and proposed joint venture sites.

VA and DOD officials identified a number of potential benefits and concerns associated with joint ventures, but they have not routinely or comprehensively documented and measured them. Among the potential benefits, VA and DOD officials and academic affiliate representatives cited improved access to care, lower or avoided costs, and improved training opportunities. While the identified benefits are many, these officials and representatives also cited a number of concerns associated with joint ventures, such as potential conflicts of missions and cultures, a loss of organizational identity and control, staffing uncertainties, and financial risks. Although able to provide anecdotal information of the benefits and concerns associated with joint ventures, officials at the joint ventures do not use performance measures to routinely or comprehensively document and assess the outcomes of the joint ventures. Without such efforts, it is difficult to know to what extent these benefits and concerns have materialized. VA also does not use performance measures at the department level to determine what is being achieved through the joint ventures--thereby making it difficult to determine the overall outcomes of the joint ventures and to hold joint venture partners accountable for results. Officials from VA and DOD and representatives from academic affiliates identified several lessons they have learned from their experiences with the existing and proposed joint ventures. These lessons include the importance of establishing joint committees to work through issues, communicating frequently with their partners, securing leadership buy-in and support at all levels, developing contingency plans, allowing adequate time to implement change, and establishing clear roles and responsibilities. For example, at most VA-DOD joint venture sites, officials have created jointly staffed committees to tackle specific issues, such as clinical, financial, and information management. Also, in New Orleans, Louisiana, VA and its academic affiliate signed a memorandum of understanding that, among other things, identifies the roles and responsibilities of the parties involved in the proposed joint venture negotiations. VA has taken steps to enhance its process for evaluating proposed joint ventures, but additional efforts are warranted. In response to our previous recommendations, VA developed and issued criteria for evaluating joint venture proposals in November 2007. In addition, VA established working groups in Charleston, South Carolina, and New Orleans to examine joint venture proposals with academic affiliates. However, VA's criteria for evaluating joint venture proposals are not sufficiently specific, in terms of both the definition and the application of the criteria. As a result, VA's evaluations of joint venture proposals could be inconsistent and, therefore, may not serve as a reliable guide for federal investments in joint ventures. In addition, the criteria are not tailored to take into account differences in prospective joint venture partners to ensure that VA applies the appropriate level of review and scrutiny to proposals.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In March 2008, GAO reported that VA had taken steps to enhance its process for evaluating proposed joint ventures, but additional efforts were warranted. In response to GAO's previous recommendations, VA developed and issued criteria for evaluating joint venture proposals in November 2007. In addition, VA established working groups in Charleston, South Carolina, and New Orleans to examine joint venture proposals with academic affiliates. However, VA's criteria for evaluating joint venture proposals are not sufficiently specific, in terms of both the definition and the application of the criteria. Therefore, GAO recommended that VA develop departmental performance measures to assess the outcomes of joint ventures and to determine the extent to which strategic goals are being achieved. In response, during 2011 the VA-DOD Joint Executive Council developed quantitative measures (when applicable) for future sharing initiatives (i.e., joint ventures) and for each existing sharing site (e.g., in terms of timeliness of access to care, level of reduction in purchased indirect care costs, level of increased direct care for patients, and the timeliness of billing and payment process as an assessment of process improvement). Additionally, the VA-DOD Joint Executive Council outlined a performance-based approach for sharing sites to define strategic goals, desired outcomes, and performance measures, and to establish a consistent method for measuring and reporting progress. As a result, VA will be better able to articulate desired outcomes of the joint ventures, determine at the department level the overall outcomes, and to hold joint venture partners accountable for results.

    Recommendation: To develop a more comprehensive framework for evaluating existing and future joint ventures, the Secretary of Veterans Affairs should develop departmental performance measures to assess the outcomes of joint ventures and to determine the extent to which strategic goals are being achieved.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Not Implemented

    Comments: In April 2012, VA officials informed us that VA no longer plans to use the evaluation criteria outlined in the handbook that was developed for evaluating joint venture proposals. For the recent joint venture that VA and DOD entered into, the officials stated that the process and criteria that were used for evaluating the joint venture was guided by the National Defense Authorization Act of 2009 (NDAA), section 706 on combined medical facilities?Guidelines for combined medical facilities of the Department of Defense and the Department of Veterans Affairs. Therefore, VA officials said there is no reason to revise the evaluation criteria in the handbook for joint venture proposals to ensure they are measurable and specific because the handbook is no longer applicable to guide such decisions. For our 2008 report, the handbook was used as the basis for making this recommendation. However, VA officials cautioned that one joint venture proposal will be totally different from another due to the variety of healthcare services that would be considered for sharing and other justifications for potentially forming the joint venture. These joint ventures may range from sharing laundry facilities to providing shared healthcare, and therefore must be based on the domain of the joint venture. The rationale for considering a joint venture proposal with the possible range of academic affiliates would dictate the evaluation criteria that should be used, but would not be a standard set of criteria that would be used for all joint venture proposals. Therefore, according to the officials, it would be very challenging and difficult to develop a standard process for evaluating joint venture proposals and the evaluation criteria that would be needed.

    Recommendation: To develop a more comprehensive framework for evaluating existing and future joint ventures, the Secretary of Veterans Affairs should revise the evaluation criteria for joint venture proposals to ensure they are measurable and specific--both in terms of definition and application.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Not Implemented

    Comments: In April 2012, VA officials informed us that VA no longer plans to use the evaluation criteria outlined in the handbook that was developed for evaluating joint venture proposals. For the recent joint venture that VA and DOD entered into, the officials stated that the process and criteria that were used for evaluating the joint venture was guided by the National Defense Authorization Act of 2009 (NDAA), section 706 on combined medical facilities?Guidelines for combined medical facilities of the Department of Defense and the Department of Veterans Affairs. Therefore, VA officials said there is no reason to revise the evaluation criteria in the handbook for joint venture proposals to ensure they are measurable and specific because the handbook is no longer applicable to guide such decisions. For our 2008 report, the handbook was used as the basis for making this recommendation. However, VA officials cautioned that one joint venture proposal will be totally different from another due to the variety of healthcare services that would be considered for sharing and other justifications for potentially forming the joint venture. These joint ventures may range from sharing laundry facilities to providing shared healthcare, and therefore must be based on the domain of the joint venture. The rationale for considering a joint venture proposal with the possible range of academic affiliates would dictate the evaluation criteria that should be used, but would not be a standard set of criteria that would be used for all joint venture proposals. Therefore, according to the officials, it would be very challenging and difficult to develop a standard process for evaluating joint venture proposals and the evaluation criteria that would be needed.

    Recommendation: To develop a more comprehensive framework for evaluating existing and future joint ventures, the Secretary of Veterans Affairs should analyze the differences among types of joint venture partners to determine whether the evaluation criteria should be tailored to the type of partner (e.g., DOD or academic affiliate) and, if so, tailor the criteria accordingly.

    Agency Affected: Department of Veterans Affairs

 

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