VA and DOD Health Care:

Department-Level Actions Needed to Assess Collaboration Performance, Address Barriers, and Identify Opportunities

GAO-12-992: Published: Sep 28, 2012. Publicly Released: Sep 28, 2012.

Additional Materials:

Contact:

Debra A. Draper
(202) 512-3000
draperd@gao.gov

 

Brenda S. Farrell
(202) 512-3604
farrellb@gao.gov

 

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(202) 512-4800
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What GAO Found

The Department of Veterans Affairs (VA) and Department of Defense (DOD) do not require that all collaboration sites--locations where the two departments share health care resources through hundreds of agreements and projects--develop and use performance measures to assess their effectiveness and efficiency. Officials cited several reasons for this, including not wanting to overburden sites with measures and monitoring requirements. Although VA and DOD require some limited performance information--such as the return on investment for pilot projects--without comprehensive performance measures, they lack information that could help decision makers assess collaboration sites' overall progress in meeting the departments' shared goals of improved health care access, quality, and costs; identify areas for improvement; and make informed decisions. Also, the departments cannot document the overall cost effectiveness of their collaboration efforts. In the absence of required measures for all sites, some have developed their own, but these fragmented efforts do not provide sufficient information about the overall results of collaborations.

The departments face a number of key barriers that hinder collaboration efforts. In particular, GAO identified incompatible policies and practices in four areas:

  • Information technology (IT) systems. Because VA and DOD collect, store, and process health information in different IT systems, providing access to information needed to best treat patients has proved problematic.

  • Business and administrative processes. Different billing practices, difficulties capturing patient workload information, and overlapping efforts in credentialing providers and computer security training reduce efficiency.

  • Access to military bases. Balancing base security needs with veterans' needs to access medical facilities on base creates some difficulties.

  • Medical facility construction. Misaligned construction planning processes hinder efforts to jointly plan facilities to serve both VA and DOD beneficiaries.

Although VA and DOD officials have taken some steps to address these areas, such as efforts to improve data sharing, without additional department-level actions, barriers will continue to hinder collaboration and lead to inefficiencies.

VA and DOD do not have a fully developed process for systematically identifying all opportunities for new or enhanced collaboration. Instead, the identification of those collaboration opportunities is largely left to local medical facility leadership. Although the departments have a process for jointly identifying a select number of sites with opportunities for new or expanded collaboration, that process does not address all opportunities for collaboration across both health care systems and there is no requirement that sites identified by that process move forward to implement collaboration. Without a fully developed process to systematically identify and select additional collaboration opportunities, the departments may miss opportunities to achieve their shared goals and reduce duplication of services, such as through additional sharing agreements.

Why GAO Did This Study

VA and DOD operate two of the nation's largest health care systems at estimated annual costs of about $53 billion and $49 billion, respectively, for fiscal year 2013, and have established collaboration sites to deliver care jointly with the aim of improving access, quality, and cost-effectiveness of care. In addition, collaborations could help reduce duplication and overlap between the two health care systems, potentially saving tax dollars and helping VA and DOD provide more efficient and effective services.

A committee report accompanying the Consolidated Appropriations Act, 2012, directed GAO to report on aspects of VA and DOD collaboration. This report examines the extent to which (1) VA and DOD assess effectiveness and efficiencies at collaboration sites; (2) barriers exist that affect collaboration; and (3) VA and DOD identify opportunities for collaboration. GAO conducted site visits to selected VA and DOD collaboration sites; reviewed VA and DOD documents such as sharing agreements; and interviewed VA and DOD officials.

What GAO Recommends

GAO recommends several actions, including that VA and DOD: require collaboration sites to develop performance measures related to access, quality, and costs; address barriers hindering collaboration; and develop a process to more systematically identify new or expanded collaboration opportunities. VA and DOD generally concurred with GAO's recommendations and noted steps they are taking to address them.

For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov, or Brenda S. Farrell at (202) 512-3604 or farrellb@gao.gov.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: The VA and DoD have identified a process for using performance measures to gauge the progress of their collaboration sites, as GAO recommended in September 2012. VA awarded a contract in November 2013 to evaluate one of the departments' collaboration sites. In November 2016, VA officials told GAO that the departments have completed their review of the evaluation results of the collaboration site and decided to pursue another evaluation model. Specifically, the evaluation models the departments chose is based on the model they used as part of a 2013 Office of Management and Budget (OMB) directed study. OMB directed VA and DoD to conduct a comparability study with the intent of increasing collaboration between the two department's health care systems. As part of this study, in November 2014, the departments began 1-year pilots to increase provider productivity and patient access in selected locations where the departments share resources to delivery care. In April 2016, VA briefed the Health Executive Committee on the results of the pilots which included an upward trend in the number and complexity of cases referred to DoD for target specialties; expanded use of a data-driven model to identify further market sharing opportunities; and collaboration on an agreement to standardize current DoD and VA reimbursement and reconciliation of shared medical services. Based on the results of the OMB-directed study, the departments have information to help ensure that collaboration sites' progress in meeting goals related to access, quality of care, and costs for health care services can be measured.

    Recommendation: To help assess progress, identify areas for improvement, and make informed decisions about health care collaborations, the Secretaries of Veterans Affairs and Defense should require collaboration sites to develop and implement a process for using performance measures to gauge their progress in achieving goals related to access, quality of care, and costs.

    Agency Affected: Department of Defense

  2. Status: Closed - Implemented

    Comments: The Department of Veterans Affairs (VA) and the Department of Defense (DOD) have identified a process for using performance measures to gauge the progress of their collaboration sites, as GAO recommended in September 2012. VA awarded a contract in November 2013 to evaluate one of the departments? collaboration sites. In November 2016, VA officials told GAO that the departments have completed their review of the evaluation results of the collaboration site and decided to pursue another evaluation model. Specifically, the evaluation model the departments chose is based on the model they used as part of a 2013 Office of Management and Budget (OMB) directed study. OMB directed VA and DOD to conduct a comparability study with the intent of increasing collaboration between the two department?s health care systems. As part of this study, in November 2014, the departments began 1-year pilots to increase provider productivity and patient access in selected locations where the departments share resources to deliver care. In April 2016, VA briefed the Health Executive Committee on the results of the pilots which included an upward trend in the number and complexity of cases referred to DOD for target specialties; expanded use of a data-driven model to identify further market sharing opportunities; and collaboration on an agreement to standardize current DOD and VA reimbursement and reconciliation of shared medical services. Based on the results of the OMB-directed study, the departments have information to help ensure that collaboration sites' progress in meeting goals related to access, quality of care, and costs for health care services can be measured.

    Recommendation: To help assess progress, identify areas for improvement, and make informed decisions about health care collaborations, the Secretaries of Veterans Affairs and Defense should require collaboration sites to develop and implement a process for using performance measures to gauge their progress in achieving goals related to access, quality of care, and costs.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: According to DOD officials, DOD and VA decided not to pursue a joint integrated electronic health record in February 2013 as they had originally planned to do. As a result, the departments did not expedite and communicate a plan for this solution. However, more recently, VA and DOD have taken actions that meet the recommendation's intent. DOD and VA have awarded contracts to the same contractor for commercial electronic health record systems-DOD in July 2015 and VA in May 2018. According to VA, it chose its electronic health record product because it should allow VA's and DOD's patient data to reside in one system, thus potentially reducing or eliminating the exchange and reconciliation of data between the two separate systems.

    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should expedite and communicate a plan with time frames for when iEHR solutions will be made available to joint ventures and other collaboration sites.

    Agency Affected: Department of Defense

  4. Status: Closed - Implemented

    Comments: According to DOD officials, DOD and VA decided not to pursue a joint integrated electronic health record in February 2013 as they had originally planned to do. As a result, the departments did not expedite and communicate a plan for this solution. However, more recently, VA and DOD have taken actions that meet the recommendation's intent. DOD and VA have awarded contracts to the same contractor for commercial electronic health record systems-DOD in July 2015 and VA in May 2018. According to VA, it chose its electronic health record product because it should allow VA's and DOD's patient data to reside in one system, thus potentially reducing or eliminating the exchange and reconciliation of data between the two separate systems.

    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should expedite and communicate a plan with time frames for when iEHR solutions will be made available to joint ventures and other collaboration sites.

    Agency Affected: Department of Veterans Affairs

  5. Status: Closed - Implemented

    Comments: VA and DOD have taken steps to resolve problems with collaboration sites' incompatible business and administrative processes, including (1) reimbursement for services, (2) collection of workload information, (3) dual credentialing, and (4) computer security training, as GAO recommended in September 2012. To address reimbursement for services and collection of workload information, in December 2016, the VA/DOD Health Executive Committee co-chairs signed the Supplement to the 2008 VA/DOD Health Care Resources Sharing Guidelines, which set in motion the standardization of both the reimbursement methodology and the care coordination process when VA patients are referred to DOD for care. In addition, in March 2019, DOD issued a memorandum to announce a new standardized DOD/VA health care resource sharing rate for services and highlights the Departments' efforts underway to pilot an advanced payment process using the 2016 Supplement. The goals of the pilot include improving the timeliness of reimbursements, and enhancing the overall sharing of resources between DOD and VA. VA officials said they continue to work with DOD to refine the reimbursement methodology and that the new guidance provides the agency with the ability to more accurately capture the workload information for care that is referred to DOD. In February 2015, VA developed the Shared Provider Registry for tracking and reporting purposes on the number of health care providers actively shared between VA and DOD. VA officials told us that prior to establishing the registry, VA and DOD had no tracking system in place to identify the number of providers who are shared between agencies. The registry allows greater visibility and tracking of providers who are credentialed with both VA and DOD. To address computer security training, VA and DOD conducted an analysis of each agency's training content to assess duplication. In October, 2016, the VA/DOD Health Executive Committee approved the Continuing Education and Training Work Group's conclusion that DOD's and VA's computer security training courses are not duplicative given that there are some differing requirements for DOD training. Also in October, 2016, the VA/DOD Health Executive Committee affirmed that VA would provide reciprocity for this training to DOD personnel, while the DOD training would be available to VA personnel. Based on these efforts, the departments have taken steps to resolve problems with collaboration sites' incompatible business and administrative processes.

    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should take steps to resolve problems with collaboration sites' incompatible business and administrative processes, including reimbursement for services, collection of workload information, dual credentialing, and computer security training.

    Agency Affected: Department of Defense

  6. Status: Closed - Implemented

    Comments: VA and DOD have taken steps to resolve problems with collaboration sites' incompatible business and administrative processes, including (1) reimbursement for services, (2) collection of workload information, (3) dual credentialing, and (4) computer security training, as GAO recommended in September 2012. To address reimbursement for services and collection of workload information, in December 2016, the VA/DOD Health Executive Committee co-chairs signed the Supplement to the 2008 VA/DOD Health Care Resources Sharing Guidelines, which set in motion the standardization of both the reimbursement methodology and the care coordination process when VA patients are referred to DOD for care. In addition, in March 2019, DOD issued a memorandum to announce a new standardized DOD/VA health care resource sharing rate for services and highlights the Departments' efforts underway to pilot an advanced payment process using the 2016 Supplement. The goals of the pilot include improving the timeliness of reimbursements, and enhancing the overall sharing of resources between DOD and VA. VA officials said they continue to work with DOD to refine the reimbursement methodology and that the new guidance provides the agency with the ability to more accurately capture the workload information for care that is referred to DOD. In February 2015, VA developed the Shared Provider Registry for tracking and reporting purposes on the number of health care providers actively shared between VA and DOD. VA officials told us that prior to establishing the registry, VA and DOD had no tracking system in place to identify the number of providers who are shared between agencies. The registry allows greater visibility and tracking of providers who are credentialed with both VA and DOD. To address computer security training, VA and DOD conducted an analysis of each agency's training content to assess duplication. In October, 2016, the VA/DOD Health Executive Committee approved the Continuing Education and Training Work Group's conclusion that DOD's and VA's computer security training courses are not duplicative given that there are some differing requirements for DOD training. Also in October, 2016, the VA/DOD Health Executive Committee affirmed that VA would provide reciprocity for this training to DOD personnel, while the DOD training would be available to VA personnel. Based on these efforts, the departments have taken steps to resolve problems with collaboration sites' incompatible business and administrative processes.

    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should take steps to resolve problems with collaboration sites' incompatible business and administrative processes, including reimbursement for services, collection of workload information, dual credentialing, and computer security training.

    Agency Affected: Department of Veterans Affairs

  7. Status: Closed - Implemented

    Comments: VA and DOD have collaborated and DOD has clarified departmental guidance to facilitate military base access for veterans and their escorts, as GAO recommended in September 2012. In January 2019, DOD issued its Manual 5200.08 Volume 3 Physical Security Program: Access to DOD Installations which clarified DOD's policy regarding access to military bases. This departmental guidance states that the forms of identification acceptable for base access now include veteran health identification cards. VA officials said this change in policy allows veterans to use their veteran health identification cards when accessing military bases for health care services such as at military treatment facilities or VA facilities located within a military base. The new policy specifies that the veteran health identification card also serves to establish the purpose for entry for individuals accompanying the veteran for health care appointments, such as caregivers. Based on the new DOD guidance, the departments have established an approach to facilitating base access for veterans and their escorts.

    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should clarify, as part of the newly initiated joint efforts to address base access, departmental guidance regarding collaboration to include a discussion of base access issues that local officials should consider when discussing and planning collaboration efforts; this could include a discussion of successful approaches that current collaboration sites have adopted to facilitate base access for veterans and their escorts.

    Agency Affected: Department of Defense

  8. Status: Closed - Implemented

    Comments: VA and DOD have collaborated and DOD has clarified departmental guidance to facilitate military base access for veterans and their escorts, as GAO recommended in September 2012. In January 2019, DOD issued its Manual 5200.08 Volume 3 Physical Security Program: Access to DOD Installations which clarified DOD's policy regarding access to military bases. This departmental guidance states that the forms of identification acceptable for base access now include veteran health identification cards. VA officials said this change in policy allows veterans to use their veteran health identification cards when accessing military bases for health care services such as at military treatment facilities or VA facilities located within a military base. The new policy specifies that the veteran health identification card also serves to establish the purpose for entry for individuals accompanying the veteran for health care appointments, such as caregivers. Based on the new DOD guidance, the departments have established an approach to facilitating base access for veterans and their escorts.

    Recommendation: To facilitate the departments' current collaboration efforts, VA and DOD should systematically identify areas where department-level actions could help address significant barriers that hinder collaboration. Specifically, the Secretaries of Veterans Affairs and Defense should clarify, as part of the newly initiated joint efforts to address base access, departmental guidance regarding collaboration to include a discussion of base access issues that local officials should consider when discussing and planning collaboration efforts; this could include a discussion of successful approaches that current collaboration sites have adopted to facilitate base access for veterans and their escorts.

    Agency Affected: Department of Veterans Affairs

  9. Status: Closed - Implemented

    Comments: The Department of Veterans Affairs (VA) and the Department of Defense (DOD) have developed a systematic process for identifying and enhancing collaboration opportunities, as GAO recommended in September 2012. VA officials told GAO that in 2014 the Office of Management and Budget directed both departments to undertake a study to systematically identify opportunities for efficiencies across both health care delivery systems. As part of this study, in November 2014, the departments began 1-year pilots to increase provider productivity and patient access in selected locations where the departments share resources to deliver care. The pilots were completed in the first quarter of fiscal year 2016. In April 2016, VA briefed the Health Executive Committee on the results of the pilots which included an upward trend in the number and complexity of cases referred to DOD for target specialties; expanded use of a data-driven model to identify further market sharing opportunities; and collaboration on an agreement to standardize current DOD and VA sharing reimbursement and reconciliation of medical services. VA officials told GAO in November 2016 that the pilots measured the effect of VA and DOD sharing on VA access and on the number and complexity of cases referred from VA to DOD. According to VA, the metrics supported the assessment that VA and DOD sharing decreased VA wait times and increased the number and complexity of patients referred to DOD. These collaboration efforts provide important opportunities for improving health care access, quality, and costs.

    Recommendation: To fully identify potential opportunities to improve access to and quality of care--and reduce costs as well as duplication and overlap between the VA and DOD health care systems--the departments should further develop a systematic process for identifying and furthering collaboration opportunities, such as through sharing agreements and joint ventures. This process should review the portfolios of the departments' health care facilities; ensure information necessary to identify collaboration opportunities is available; identify both new and expanded opportunities for collaboration; and assign responsibility to ensure identified opportunities are explored and implemented if appropriate.

    Agency Affected: Department of Defense

  10. Status: Closed - Implemented

    Comments: The Department of Veterans Affairs (VA) and the Department of Defense (DOD) have developed a systematic process for identifying and enhancing collaboration opportunities, as GAO recommended in September 2012. VA officials told GAO that in 2014 the Office of Management and Budget directed both departments to undertake a study to systematically identify opportunities for efficiencies across both health care delivery systems. As part of this study, in November 2014, the departments began 1-year pilots to increase provider productivity and patient access in selected locations where the departments share resources to deliver care. The pilots were completed in the first quarter of fiscal year 2016. In April 2016, VA briefed the Health Executive Committee on the results of the pilots which included an upward trend in the number and complexity of cases referred to DOD for target specialties; expanded use of a data-driven model to identify further market sharing opportunities; and collaboration on an agreement to standardize current DOD and VA sharing reimbursement and reconciliation of medical services. VA officials told GAO in November 2016 that the pilots measured the effect of VA and DOD sharing on VA access and on the number and complexity of cases referred from VA to DOD. According to VA, the metrics supported the assessment that VA and DOD sharing decreased VA wait times and increased the number and complexity of patients referred to DOD. These collaboration efforts provide important opportunities for improving health care access, quality, and costs.

    Recommendation: To fully identify potential opportunities to improve access to and quality of care--and reduce costs as well as duplication and overlap between the VA and DOD health care systems--the departments should further develop a systematic process for identifying and furthering collaboration opportunities, such as through sharing agreements and joint ventures. This process should review the portfolios of the departments' health care facilities; ensure information necessary to identify collaboration opportunities is available; identify both new and expanded opportunities for collaboration; and assign responsibility to ensure identified opportunities are explored and implemented if appropriate.

    Agency Affected: Department of Veterans Affairs

 

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