VA AND DOD 

HEALTH CARE

Department-Level 

Actions Needed to 

Assess Collaboration 

Performance, Address 

Barriers, and Identify 

Opportunities

Report to Congressional Addressees

September 2012

GAO-12-992

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United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-992, a report to 

congressional addressees

September 2012

VA AND DOD HEALTH CARE

Department-Level Actions Needed to Assess 

Collaboration Performance, Address Barriers, and 

Identify Opportunities

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 costeffectiveness 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.

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.

View GAO-12-992. 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.
Page i GAO-12-992 VA and DOD Collaboration

Letter 1 

Background 5

VA and DOD Do Not Require Participants in All Types of 

Collaboration to Develop Performance Measures to Assess Their 

Effectiveness and Efficiency 10

VA and DOD Face Several Significant Barriers That Hinder 

Collaboration, Despite Taking Some Actions to Address Those 

Barriers 13

VA and DOD Do Not Have a Fully Developed Process for 

Systematically Identifying New and Enhanced Collaboration 

Opportunities 33

Conclusions 37

Recommendations for Executive Action 37

Agency Comments and Our Evaluation 38

Appendix I Comments from the Department of Defense 42

Appendix II Comments from the Department of Veterans Affairs 45

Appendix III GAO Contacts and Staff Acknowledgments 49

Table

Table 1: Key Features and Prevalence of VA/DOD Collaboration 

Options as of June 2012 9

Figures

Figure 1: Organizational Components Related to VA/DOD 

Collaboration 7

Figure 2: Location of VA/DOD Joint Ventures, as of August 2012 8

Figure 3: Example of the Side-by-Side Dual Computers Used by 

Staff at the Joint Venture in Biloxi, Mississippi, to Access 

VA and DOD Computer Systems 15

Figure 4: Signage at the Entrance to the Base That Houses Tripler 

Army Medical Center in Honolulu, Hawaii 25

Contents
Page ii GAO-12-992 VA and DOD Collaboration

Figure 5: Traffic Approaching the Entrance to the Base That 

Houses Tripler Army Medical Center in Honolulu, Hawaii, 

with the Medical Center Shown in the Background 28

Abbreviations

DOD Department of Defense

eDR enhanced Document Management and Referral 

 Management

iEHR integrated electronic health record

IPO Interagency Program Office

IT information technology

JIF Joint Incentive Fund

JMO joint market opportunity

VA Department of Veterans Affairs

VISN Veterans Integrated Service Network

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-12-992 VA and DOD Collaboration

United States Government Accountability Office

Washington, DC 20548

September 28, 2012

Congressional Addressees

The Departments of Veterans Affairs (VA) and Defense (DOD) operate 

two of the nation’s largest health care systems, together providing health 

care to nearly 16 million veterans, servicemembers, military retirees, and 

other beneficiaries at estimated annual costs of about $53 billion and 

$49 billion, respectively, for fiscal year 2013.1 Although the two 

departments have different missions, both provide health care services 

and have been authorized to exchange health care resources since the 

1982 enactment of the Veterans’ Administration and Department of 

Defense Health Resources Sharing and Emergency Operations Act.2

Specifically, VA and DOD were authorized by the act to enter into 

contracts or sharing agreements to improve access to, and the quality 

and cost-effectiveness of, health care provided by the two departments. 

Subsequently, the departments have instituted a policy that allows VA 

and DOD to charge one another at least 10 percent less for clinical 

services than they would in locations without sharing agreements.3

Since the 1980s, VA and DOD have entered into many types of 

collaborations to provide health care services—including emergency, 

specialty, inpatient, and outpatient care—to VA and DOD beneficiaries, 

reimbursing each other for the services provided. These collaborations 

vary in scope, ranging from agreements to jointly provide a single type of 

service to more coordinated “joint ventures,” which encompass multiple 

health care services and facilities and focus on mutual benefit, shared 

risk, and joint operations in specific clinical areas. The departments also 

have collaborated on the joint construction of medical facilities and have 

 

1

DOD’s fiscal year 2013 budget request for its Unified Medical budget includes 

$32.5 billion for the Defense Health Program, $8.5 billion for military medical personnel, 

$1.0 billion for military construction, and $6.7 billion set aside for the Medicare-Eligible 

Retiree Health Care Fund. The total excludes overseas contingency operations funds.

2

See 38 U.S.C. § 8111. The Department of Veterans Affairs was previously known as the 

Veterans Administration.

3

In a memorandum of understanding effective in fiscal year 2003, the departments 

established a policy for reimbursement for health care services they share, which allows 

the collaborating facilities to use a 10 percent discount from the standard allowable charge 

for clinical services and certain specialty services.

 
 

Page 2 GAO-12-992 VA and DOD Collaboration

jointly funded pilot projects related to VA and DOD collaboration activities. 

The Secretaries of Veterans Affairs and Defense both have expressed 

their commitment to greater collaboration between the two departments 

on several issues of common interest, including better health care access 

for servicemembers, veterans, and other VA and DOD beneficiaries, and 

to most effectively use resources.

VA and DOD’s current and future efforts to collaborate on the delivery of 

health care services have the potential to yield significant cost savings 

and other benefits, such as a reduction in the duplication of health care 

services.4 We have previously reported that reducing or eliminating 

government-wide duplication could potentially save billions of tax dollars 

annually and help agencies provide more efficient and effective services.5

This is especially important for VA and DOD given that the departments 

have experienced and continue to experience rising health care costs. 

Specifically, both VA’s and DOD’s fiscal year 2013 budget requests 

reflect anticipated medical care expenses that are more than double their 

2001 costs. Duplication and overlap can occur for a variety of reasons, 

including that agencies lack information on the effectiveness of programs 

that could help decision makers prioritize resources among programs. We 

have previously identified the need for improvement in the evaluation of 

current and potential VA/DOD collaboration efforts, as well as challenges 

VA and DOD face in their efforts to share health care resources.6

A committee report accompanying the Consolidated Appropriations Act, 

2012, directed GAO to report on aspects of VA and DOD collaboration.

Efforts 

leading to a reduction in duplication and overlap can help inform decision 

makers as they address escalating fiscal pressures currently facing the 

federal government.

7

 

4

Collaboration can be broadly defined as any joint activity that is intended to produce 

more public value than could be produced when the organizations act alone.

In this report, we examine the extent to which

5

GAO, Opportunities to Reduce Potential Duplication in Government Programs, Save Tax 

Dollars, and Enhance Revenue, GAO-11-635T (Washington, D.C.: May 25, 2011).

6

GAO, VA Health Care: Additional Efforts to Better Assess Joint Ventures Needed, 

GAO-08-399 (Washington, D.C.: Mar. 28, 2008) and VA and DOD Health Care: First 

Federal Health Care Center Established, but Implementation Concerns Need to Be 

Addressed, GAO-11-570 (Washington, D.C.: July 19, 2011).

7

H.R. Rep. No. 112-94, at 52 (2011). 
 

Page 3 GAO-12-992 VA and DOD Collaboration

1. VA and DOD assess effectiveness and efficiency for locations where 

they collaborate to deliver joint health care services; 

2. Barriers exist that affect VA and DOD collaboration to deliver joint 

health care services, and whether the departments have developed 

strategies to address these barriers; and

3. VA and DOD identify opportunities for collaboration to deliver joint 

health care services.

To address these three objectives, we conducted site visits, attended the 

2011 VA and DOD joint venture conference, reviewed documentation, 

conducted interviews with VA and DOD officials, and reviewed relevant 

GAO reports.8

• We conducted site visits to 2 of the 10 joint ventures—Honolulu, 

Hawaii, and Biloxi, Mississippi—where we met with officials from VA 

and DOD to discuss and observe their collaboration efforts.9 We also 

reviewed and analyzed documents from the locations we visited, such 

as sharing agreements, performance measures, and any estimates 

local officials had calculated of cost savings related to their 

collaboration. As part of the site visit to Biloxi, we also met with 

leaders from nearby military treatment facilities that collaborate with 

that VA facility.10 In addition, we visited Ft. Benning in Columbus, 

Georgia and interviewed VA and DOD officials to learn about plans for 

collaboration in that location.

 

8

Since 2004, VA and DOD have convened an annual conference to highlight the progress 

and accomplishments of joint ventures, as well as provide a forum for discussing common 

barriers to success, lessons learned, and best practices. The 2011 conference was held in 

Charleston, South Carolina, in October 2011.

9

We selected these two joint venture locations because they represented a range of 

collaboration efforts, as well as collaboration involving all three military services—the 

Army, the Navy, and the Air Force. The VA and DOD partners at the Honolulu joint 

venture are Tripler Army Medical Center and the VA Pacific Islands Health Care System, 

and at the Biloxi joint venture are Keesler Medical Center/81st Medical Group at Keesler 

Air Force Base and the VA Gulf Coast Veterans Health Care System. The remaining eight 

joint ventures are located in Albuquerque, New Mexico; Anchorage, Alaska; Charleston, 

South Carolina; El Paso, Texas; Fairfield, California; Key West, Florida; Las Vegas, 

Nevada; and North Chicago, Illinois.

10We met with leaders from Naval Hospital Pensacola, the 96th Medical Group at Eglin Air 

Force Base, and the 325th Medical Group at Tyndall Air Force Base in Florida about their 

collaboration with the VA Gulf Coast Veterans Health Care System.
 

Page 4 GAO-12-992 VA and DOD Collaboration

• We attended the annual VA and DOD joint venture conference in 

October 2011, where we obtained information during detailed 

presentations given by all 10 joint ventures regarding their 

collaboration efforts, the problems they face, and plans for future 

sharing opportunities; heard presentations by VA and DOD 

department-level officials; and toured the Charleston, South Carolina, 

joint venture site.11 This information led to the identification of key 

barriers affecting VA and DOD collaboration.12

• We reviewed and analyzed relevant VA and DOD documentation, 

including the VA/DOD Joint Strategic Plan for Fiscal Years 2011-2013 

(Joint Strategic Plan) and departmental and joint VA/DOD guidance 

regarding collaboration options, approaches used to identify 

opportunities for collaboration, and performance measures required of 

collaborating VA and DOD partners.

• We interviewed VA and DOD department-level officials, including 

officials from both departments’ collaboration offices, construction 

planning offices, and the Interagency Program Office responsible for 

joint VA/DOD information technology (IT) initiatives. We also 

interviewed officials from the three military services—the Army, the 

Navy, and the Air Force—who are involved with VA/DOD 

collaboration efforts,13 as well as officials from some of VA’s 21 

regional Veterans Integrated Service Networks (VISN).14

• We reviewed our past work, including reports on best practices for 

federal agency collaboration efforts, VA and DOD’s efforts to share 

medical information between the two departments, the status of VA 

and DOD’s efforts to establish an integrated federal health care center 

 

11The partners at the Charleston joint venture are: Ralph H. Johnson Veterans Affairs 

Medical Center; Naval Health Clinic Charleston; the Air Force’s 628th Medical Group; and 

the Naval Hospital Beaufort.

12We defined key barriers as those issues that were factors across multiple collaboration 

sites or posed significant difficulties at one or more sites. 

13The Navy is responsible for providing health care to members of the Marine Corps and 

their beneficiaries.

14VA’s health care system is organized into 21 VISNs charged with the day-to-day 

management of the medical facilities within their network. VA’s Central Office is 

responsible for monitoring and overseeing VISN and medical center operations.
 

Page 5 GAO-12-992 VA and DOD Collaboration

in North Chicago, Illinois, and best practices for establishing 

evaluation criteria to assess federal programs.15

We conducted this performance audit from November 2011 through 

September 2012 in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives.

VA and DOD have distinct missions and health care systems to provide 

services to their respective beneficiaries. VA and DOD provide some 

similar services in locations where they have facilities near each other, 

and have established an organizational structure to plan and carry out a 

variety of joint projects. In addition, there are several options for VA and 

DOD collaboration to deliver health care services jointly.

In addition to having separate missions—VA’s to serve America’s 

veterans, and DOD’s to provide the military forces needed to deter war 

and protect the country’s security—the departments have distinct health 

care systems through which they provide a range of health care services 

to their respective beneficiaries.16

 

15See GAO, VA and DOD Health Care: First Federal Health Care Center Established, but 

Implementation Concerns Need to Be Addressed, 

In addition, each has a framework that 

outlines its vision and goals for the care and services they deliver. 

GAO-11-570 (Washington, D.C.: 

July 19, 2011); VA/DOD Federal Health Care Center: Costly Information Technology 

Delays Continue and Demonstration Evaluation Plan Lacking, GAO-12-669 (Washington, 

D.C.: June 26, 2012); Results-Oriented Government: Practices That Can Help Enhance 

and Sustain Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: 

Oct. 21, 2005); Limitations in DOD’s Evaluation Plan for EEO Complaint Pilot Program 

Hinder Determination of Pilot Results, GAO-08-387R (Washington, D.C.: Feb. 22, 2008); 

Tax Administration: IRS Needs to Strengthen Its Approach for Evaluating the SRFMI 

Data-Sharing Pilot Program, GAO-09-45 (Washington, D.C.: Nov. 7, 2008).

16VA beneficiaries include veterans of military service and certain dependents and 

survivors. DOD beneficiaries include active duty servicemembers and their dependents, 

medically eligible National Guard and Reserve servicemembers and their dependents, 

and military retirees and their dependents and survivors.

Background 

VA and DOD Health Care 

Systems
 

Page 6 GAO-12-992 VA and DOD Collaboration

VA’s health care system includes a network of approximately 150 

hospitals, 130 nursing homes, 800 community-based outpatient clinics, as 

well as other facilities to provide care to veterans. VA also purchases care 

from outside its network as needed to provide services for its 

beneficiaries. VA estimates it will serve 6.3 million patients in the VA 

health care system in fiscal year 2013 and has requested $52.7 billion for 

its health care services for that year. VA’s “I CARE” framework broadly 

outlines the department’s goals for delivering health care services and in 

particular, cites the importance of access to, and the quality and cost of, 

VA health care.

DOD’s health care system—known as the Military Health System— 

serves about 9.6 million beneficiaries. According to a 2011 Congressional 

Budget Office report, DOD’s health care costs are projected to reach 

$59 billion by 2016 and nearly $92 billion by 2030.17 DOD provides care 

through its system of approximately 60 military treatment facilities that 

provide diagnostic, therapeutic, and inpatient care; hundreds of clinics; 

and by purchasing care from a network of private-sector civilian 

providers.18 Each of the military services, under its respective surgeon 

general, is responsible for managing its own military treatment facilities. 

The Military Health System’s “Quadruple Aim” outlines the department’s 

vision for delivering health care services and—similar to VA’s I CARE 

framework—emphasizes health care access, quality, and costs.

VA and DOD have an organizational structure in place to plan and carry 

out a variety of joint projects and collaboration efforts. (See fig. 1.)

 

17Congressional Budget Office, Long-Term Implications of the 2012 Future Years Defense 

Program, Pub. No. 4281 (June 2011).

18Under DOD’s TRICARE program, beneficiaries can obtain care either from providers at 

military treatment facilities or from civilian providers.

VA and DOD Organization 

for Collaboration and Joint 

Strategic Planning
 

Page 7 GAO-12-992 VA and DOD Collaboration

Figure 1: Organizational Components Related to VA/DOD Collaboration 

Specifically, the Joint Executive Council—co-chaired by the Deputy 

Secretary of VA and the Under Secretary of Defense for Personnel and 

Readiness—is made up of senior VA and DOD officials and provides 

broad strategic direction for interagency collaboration between the two 

departments. The Health Executive Council, a subcouncil of the Joint 

Executive Council, provides oversight for the specific cooperative efforts 

of each department’s health care organizations. The Health Executive 

Council has organized itself into a number of work groups to carry out its 

responsibilities. For example, Health Executive Council work groups 

focus on issues such as financial management, pharmacy, and IT, among 

several others. In addition to this interagency structure, there are 

department-level coordination offices—VA’s VA/DOD Sharing Office and 

DOD’s DOD/VA Program Coordination Office. These offices coordinate 

with, but do not have a direct reporting relationship to the Joint Executive 

Council and the Health Executive Council.

The Joint Executive Council and the Health Executive Council also 

provide oversight to the 10 joint ventures by providing some level of 
 

Page 8 GAO-12-992 VA and DOD Collaboration

direction and support for their activities. (See fig. 2 for the locations of the 

current joint ventures.)

Figure 2: Location of VA/DOD Joint Ventures, as of August 2012

Further, the Joint Executive Council has developed the Joint Strategic 

Plan, which conveys the direction and goals for collaboration efforts for 

the two departments. The plan outlines the departments’ primary goals, 

which include developing a health care system that delivers quality, 

access, satisfaction, and value, consistently across the departments, and 

establishes a national model for effective and efficient delivery of benefits 

and services through collaboration. The plan also outlines specific 

initiatives designed to ensure leadership, commitment, and accountability 

for VA and DOD’s collaboration activities.

There are three primary options for collaboration that VA and DOD may 

pursue to jointly deliver health care services: sharing agreements, joint 

ventures, and Joint Incentive Fund (JIF) projects (see table 1). 

Collaboration sites can pursue a combination of these sharing options. 

Options for VA and DOD 

Collaboration to Deliver 

Health Care Services
 

Page 9 GAO-12-992 VA and DOD Collaboration

For example, a site with sharing agreements in place can pursue joint 

venture status or JIF project funding. In addition to these collaboration 

options, the departments are required by law to consult with each other 

regarding certain potential joint construction projects.19

Table 1: Key Features and Prevalence of VA/DOD Collaboration Options as of June 2012

Department-level 

officials from VA and DOD identify opportunities for joint construction and 

coordinate through their respective budgeting and construction planning 

processes.

Collaboration option Key features Prevalence 

Sharing agreement • Ranges in complexity and scope from sharing a single service to agreements 

that govern the sharing of multiple services

• Allows partners to reimburse each other for services or procedures provided to 

beneficiaries at negotiated rates, at a cost savings of at least 10 percent

• Local partners identify opportunities

• Veterans Integrated Service Networks (VISN),a DOD counterparts, and 

department-level staff review agreement and determine whether to implement

Nearly 200 active 

sharing agreements in 

place

Joint venture • Shares multiple health care services and sometimes facilities

• Has increased flexibility to determine reimbursement rates than with sharing 

agreements alone

• Local partners typically decide whether to pursue the option and VA and DOD 

department-level staff make the formal designation

10 joint ventures

Joint Incentive Fund 

(JIF) project

• Provides funding for pilot projects that may result in new sharing agreements

• VA and DOD jointly issue a call for JIF project proposals at least once per year

• Locations with sharing agreements in place, joint ventures, and other sites may 

apply for funding

• Typically, local VA and DOD partners determine whether to apply 

Since Congress 

established the JIF in 

2003,b 130 projects 

funded, totaling 

$418 millionc

Source: GAO.

a

VA’s health care system is organized into 21 VISNs charged with the day-to-day management of the 

medical facilities within their network.

b

Bob Stump National Defense Authorization Act for Fiscal Year 2003, Pub. L. No. 107-314, § 

721(a)(1), 116 Stat. 2458, 2591 (2002) (codified as amended at 38 U.S.C. § 8111(d)).

c

Totals include projects funded from 2004 through 2012.

 

19Pub. L. No. 108-375, div. B, title XXVIII, § 2811, 118 Stat. 1811, 2128-29 (2004).
 

Page 10 GAO-12-992 VA and DOD Collaboration

We have reported extensively on the importance of developing and using 

performance measures for effective management and strategic planning, 

as well as for measuring the achievement of projected cost savings, and 

other performance goals.20 Furthermore, we have noted that such 

performance measurement information can assist decision makers in 

assessing progress and identifying areas for improvement. In addition, 

the VA and DOD health care collaboration statute,21

Performance measures are important to show the extent of progress 

made in improving access and quality of care, in addition to cost savings 

achieved, if any, from collaborations. For example, although VA and DOD 

department-level officials believe that some savings occur when 

collaboration sites adopt sharing agreements in which partners pay each 

other less for care than they would otherwise pay community providers, 

the overall savings are unclear because sites are not required to develop 

performance measures to assess the extent of their savings. The 

importance of performance measures regarding costs is highlighted by 

our prior work on the consolidation and integration of federal facilities—in 

particular, how such activities can result in unexpected costs that may 

affect overall results. For example, the North Chicago Federal Health 

Care Center joint venture experienced unanticipated costs associated 

with its integration of VA and DOD services, such as hiring the equivalent 

of 23 full-time staff to manually perform work that was originally expected 

to be automated. The impact of these additional costs on that integration 

overall, however, is unknown, because VA and DOD have not established 

cost-related performance measures.

as well as VA and 

DOD’s own health care goals, all highlight access, quality, and costs as 

important considerations in the delivery of health care. Finally, VA and 

DOD department-level officials said it is important to consider costs as a 

part of both departments’ responsibilities to ensure their collaboration 

efforts are financially sound and improve care.

22

 

20See 

 Without performance measures in 

GAO-06-15, GAO-12-669, GAO, VA and DOD Health Care: Opportunities to 

Maximize Resource Sharing Remain, GAO-06-315 (Washington, D.C.: Mar. 20, 2006), 

and VA Health Care: Additional Efforts to Better Assess Joint Ventures Needed, 

GAO-08-399 (Washington, D.C.: Mar. 28, 2008).

21See 38 U.S.C. § 8111, which cites improving access, quality, and cost effectiveness as 

health care collaboration goals.

22GAO-12-669. Similarly, some of the integration and closures that occurred as a result of 

the 2005 Military Base Realignment and Closures round ultimately resulted in unexpected 

cost increases that affected the amount of savings DOD was able to achieve.

VA and DOD Do Not 

Require Participants 

in All Types of 

Collaboration to 

Develop Performance 

Measures to Assess 

Their Effectiveness 

and Efficiency
 

Page 11 GAO-12-992 VA and DOD Collaboration

place to assess VA and DOD’s collaboration efforts, the overall value of 

these efforts is unclear.

According to VA and DOD department-level officials, the departments do 

not require that all collaboration sites develop and use performance 

measures to assess the collaborations’ effectiveness and efficiency, in 

particular to measure their progress in meeting the departments’ shared 

goals of improved health care access, quality, and costs. Officials from 

both departments cited several reasons why VA and DOD do not require 

all collaboration sites to develop and use performance measures related 

to the departments’ shared goals. In particular, VA officials told us they do 

not want to overburden sites with performance measures and monitoring 

requirements, which they said may discourage future collaborations. VA 

officials also told us that department-level VA and DOD collaboration 

offices do not have direct control over medical facilities and are not 

required to provide oversight or monitoring of performance. Finally, DOD 

officials said that because each collaboration is unique, performance 

measures appropriate for one location might not be appropriate for 

another location.

Although VA and DOD do not require all collaboration sites to develop 

and use performance measures, the departments do require some limited 

performance information for certain collaboration options. For example, to 

receive JIF project funding, sites must estimate the return on investment 

and propose performance measures related to that estimate and other 

projected benefits, such as improved access or quality of care. Sites that 

receive such funding must then periodically use and report on those 

performance measures during and at the conclusion of the project. In 

addition, beginning in fiscal year 2013, joint ventures and other selected 

collaboration sites will be required to report on performance measures to 

indicate areas where sites have achieved at least a 5 percent reduction in 

costs or other improvements in efficiency that result from health care 

collaborations. VA officials told us these measures are not meant to 

represent overall savings achieved as a result of collaborating, but rather 

savings from specific, self-selected areas the collaboration sites choose 

to measure. Although these efforts represent initial steps toward better 

understanding of the performance and progress of collaboration sites, 

officials acknowledged that more work remains to be done. VA and DOD 

officials told us that both departments are working to develop criteria to 

determine the success of the 10 joint ventures, which they anticipate will 

be based on the departments’ shared goals. As of July 2012, VA 

department-level officials told us that a set of proposed criteria were still 

being reviewed internally. They noted that the time frame for 
 

Page 12 GAO-12-992 VA and DOD Collaboration

implementing those criteria would still need to be determined, in part 

because the departments would need to resolve data collection and 

analysis issues—such as ensuring that collaboration partners had access

to reliable and timely information—before any resulting measures could 

be developed and used to assess sites’ progress.

In the absence of a department-level requirement for performance 

measures for all collaboration sites, some sites we reviewed have 

developed their own performance measures. Although this information 

may assist local medical facility leaders to understand the progress and 

areas for improvement at their sites, the fragmented nature of these 

efforts does not provide department-level decision makers with 

information about overall performance or results of VA and DOD 

collaborations. For example:

• Officials from the Biloxi VA and one of their DOD collaboration 

partners, Naval Hospital Pensacola,23 told us that their established 

discounts for the inpatient services that DOD provides to VA patients 

through a sharing agreement—the standard 10 percent discount from 

fiscal years 2009 through 2011, changed to a larger 25 percent 

discount beginning in June 2012—had resulted in a reported 

cumulative savings of about $200,000 for VA since fiscal year 2009, 

as of July 2012.24

• Honolulu joint venture officials reported that they assess efficiency by 

tracking the amount of time it takes to schedule appointments for 

patients who were referred to them by their collaboration partner. 

Additionally, they measure quality of care using measures derived 

from patient feedback information. Officials told us that by assessing 

these measures they are able to identify trends and help ensure that 

patients are accessing health care.

 

23The Gulf Coast Veterans Health Care System located in Biloxi collaborates with the 

Naval Hospital Pensacola separately from its joint venture with Keesler Air Force Base.

24This figure was self-reported by the VA and DOD partners at this collaboration site. We 

did not complete a data reliability assessment because these data are being used for 

illustrative purpose only.
 

Page 13 GAO-12-992 VA and DOD Collaboration

VA and DOD face a number of significant barriers that hinder their 

collaboration efforts. We have previously reported that federal agencies 

can facilitate and enhance their collaboration efforts by establishing 

compatible policies, procedures, and other ways of operating across 

boundaries.25 Some problems VA and DOD face are inherent to the 

differing missions of the two departments.26 However, we also identified 

several important areas where VA and DOD’s lack of compatible policies 

and practices at the department level and at local collaboration sites 

hinders collaboration efforts. These incompatible policies and practices 

fall into four areas: (1) IT systems’ ability to share health information, 

(2) business and administrative processes in place at current 

collaboration sites, (3) procedures for veterans to access medical facilities 

on military bases, and (4) joint VA and DOD planning for construction of 

medical facilities. Although VA and DOD officials at the department and 

local levels have taken some steps to address issues in these areas, 

significant barriers remain. Without additional department-level actions to 

address incompatible policies and practices, those barriers will continue 

to hinder collaboration efforts and lead to inefficiencies at the local level.

As we have reported for over a decade, VA and DOD lack IT systems that 

permit the electronic exchange of comprehensive patient health 

information, a significant barrier in their collaboration efforts.27

 

25

Access to 

comprehensive health information is important to providing optimal care 

to patients who receive health care services from both VA and DOD. 

However, because VA and DOD collect, store, and process health 

GAO-06-15. 

26For example, one of the primary missions of DOD medical personnel is to provide 

medical support for military operations, requiring them to deploy to other locations. This 

can lead to vacancies at some facilities when military operations occur and other medical 

personnel are not available to take the place of those who deploy. In addition, leadership 

at military treatment facilities frequently changes due to periodic personnel reassignment 

to different duty stations.

27See, for example, GAO, Electronic Health Records: DOD and VA Efforts to Achieve 

Full Interoperability Are Ongoing; Program Office Management Needs Improvement, 

GAO-09-775 (Washington, D.C.: July 28, 2009); Electronic Health Records: DOD and VA 

Interoperability Efforts Are Ongoing; Program Office Needs to Implement Recommended 

Improvements, GAO-10-332 (Washington, D.C.: Jan. 28, 2010); and Electronic Health 

Records: DOD and VA Should Remove Barriers and Improve Efforts to Meet Their 

Common System Needs, GAO-11-265 (Washington, D.C.: Feb. 2, 2011). 

VA and DOD Face 

Several Significant 

Barriers That Hinder 

Collaboration, 

Despite Taking Some 

Actions to Address 

Those Barriers

IT Systems’ Ability to 

Share Health Information
 

Page 14 GAO-12-992 VA and DOD Collaboration

information in different IT systems, providing access to the information 

needed to best treat those patients has proved problematic.

At collaboration sites, the departments’ IT barriers hinder ongoing efforts 

in many ways. As we have previously reported, a health care provider 

who lacks access to comprehensive health information about a patient 

may be challenged to make the most informed treatment decisions, 

potentially putting the patient’s health at risk. The provider also might 

unknowingly order diagnostic tests that have already been performed, 

leading to added health care costs. In addition, providers’ inability to use 

their own facility’s IT system to easily view the health care records of their 

collaboration partner’s patients can lead to costly inefficiencies. For 

example, the North Chicago Federal Health Care Center joint venture 

hired five full-time pharmacists specifically to conduct manual checks of 

patient records to reconcile allergy information and identify possible 

interactions between drugs prescribed by providers in both VA and DOD 

systems. Similarly, Biloxi joint venture officials reported having to rely on 

inefficient and time-consuming approaches to share information, including 

manually copying or transferring medical information such as diagnostic 

images between VA’s and DOD’s IT systems, or faxing information to 

their collaboration partner, where it must be entered into the partner’s IT 

system. 

Collaboration sites have taken steps to facilitate information sharing, but 

officials noted that those efforts had limitations and that IT barriers 

remained. For example, Honolulu joint venture officials developed an IT 

tool—called “Janus”—that allows providers to view their patients’ VA and 

DOD health care records on a single screen. Officials said this tool has 

helped providers treating shared patients in a number of ways, providing 

clinical benefits and allowing providers to work more efficiently. Officials 

said, for example, that Janus gives providers a more efficient way to view 

and share diagnostic images taken by collaboration partners and to 

compare clinical information in both partners’ systems, such as patients’ 

medication allergies and laboratory results. However, they noted that it is 

a “read only” tool that doesn’t allow providers to enter data into the other 

department’s IT system; as a result, there are some inefficiencies when 

providers must take time to separately perform data entry steps outside of 

their Janus IT tool. At the Biloxi joint venture, staff in some clinical areas 

use side-by-side dual computers: one to access VA health care records 

and another to access DOD health care records. (See fig. 3.) Biloxi 

officials reported that although this approach helps, it is time-consuming 

and costly, and does not allow staff to share information as efficiently as 

they would like; for example, there are costs to set up the dual computers 
 

Page 15 GAO-12-992 VA and DOD Collaboration

and it takes providers extra time to access both IT systems to review 

information and share information with their collaboration partners. Biloxi 

officials also are working with VA and DOD at the department level to test 

a way of electronically sharing diagnostic images between facilities.

Figure 3: Example of the Side-by-Side Dual Computers Used by Staff at the Joint 

Venture in Biloxi, Mississippi, to Access VA and DOD Computer Systems

At the department level, VA and DOD have worked for many years to 

improve the ability of their IT systems to share medical information, and 

have spent millions of dollars on those efforts, but those efforts have not 

yet led to a comprehensive solution. As we have reported, VA and DOD 

have increased their ability to electronically share information through a 
 

Page 16 GAO-12-992 VA and DOD Collaboration

patchwork of initiatives.28 In April 2009, the President announced that the 

departments would define and build the Virtual Lifetime Electronic Record 

to streamline the transition of electronic medical, benefits, and 

administrative information between the departments.29 Over the past few 

years, the departments also began working to develop IT capabilities to 

facilitate information sharing at the North Chicago Federal Health Care 

Center joint venture that were intended to be “exportable” for use at other 

VA and DOD collaboration sites. However, those efforts have been 

delayed, in some cases indefinitely, resulting in costly and inefficient 

workarounds.30

Most recently, the departments began work on a new common integrated 

electronic health record (iEHR) that both VA and DOD would use for their 

beneficiaries. In March 2011, the Secretaries of VA and Defense 

committed the two departments to developing this new health record and 

in May 2012 announced their goal of implementing it across the 

departments by 2017. Officials from the joint DOD/VA Interagency 

Program Office (IPO),31

 

28For example, the Federal Health Information Exchange, begun in 2001 and completed 

in 2004, allows DOD to electronically transfer servicemembers’ health information to VA 

when they leave active duty. In addition, the departments’ Bidirectional Health Information 

Exchange was established in 2004 to allow clinicians in both departments to view limited 

health information on patients who receive care from both departments. Also, the Clinical 

Data Repository/Health Data Repository interface, implemented in 2006, linked the 

departments’ separate repositories of standardized data to enable a two-way exchange of 

computable outpatient pharmacy and medication allergy information. See 

which is leading the iEHR effort, told us they have 

substantial financial resources for the iEHR effort, reporting funding of 

GAO-11-265. 

29The Virtual Lifetime Electronic Record initiative is intended to enable access to all

electronic records for servicemembers as they transition from military to veteran status, 

and to enable DOD, VA, and the private sector to share medical, benefits, and 

administrative information to support servicemembers as they make that transition.

30The agreement that established the North Chicago Federal Health Care Center stated 

that the IT capabilities developed for that location would be exportable to other 

collaboration sites. See GAO-11-570. 

31In January 2009, the departments established the IPO under the Joint Executive Council 

to act as a single point of accountability for DOD’s and VA’s joint efforts to develop and 

implement electronic health record systems or capabilities to enable full interoperability of 

the departments’ health care information, in accordance with the National Defense 

Authorization Act for Fiscal Year 2008. The IPO was initially responsible for integrating 

DOD’s and VA’s program management plans and activities for their joint health IT 

initiatives. However, under its new charter as of October 2011, the IPO has added 

responsibilities. For example, it now has joint authorization to lead, oversee, and manage 

all interagency activities related to iEHR as well as other joint IT efforts.
 

Page 17 GAO-12-992 VA and DOD Collaboration

nearly $550 million across both VA and DOD for iEHR in fiscal year 2012 

alone.32

However, the implementation time frame for the new iEHR effort is 

uncertain. IPO officials told us in April 2012 that they planned to 

implement elements of iEHR in a phased approach over time, but that full 

implementation may not occur for at least 4 to 6 years, and that this 

estimated time frame was both optimistic and uncertain. They said the 

IPO office was not yet fully staffed, nor did they have final plans for how 

iEHR would be developed and implemented given that many decisions 

had yet to be made. For example, they had not yet determined what 

clinical applications iEHR would include, the time frame for implementing 

different elements of iEHR across all VA and DOD sites, or the order in 

which they would implement iEHR at collaboration sites. IPO officials 

noted that once they complete their work at the iEHR pilot sites they will 

have a better sense of how the project would proceed. They added that 

they might select a limited number of other sites to use elements of iEHR 

as part of their early work on the project; they noted that although they 

had not yet developed criteria for selecting those additional sites, the joint 

venture sites would be among those considered.

They also said they have made some key decisions about the 

project. For example, IPO officials plan to begin work at the Honolulu joint 

venture in September 2012 on IT tools that would be part of the larger 

iEHR effort, and test initial elements of iEHR at two pilot sites in 2014.

Overall, given the uncertainty about when and how iEHR will be 

implemented, it is not clear when collaboration sites could expect to see 

benefits from this new effort. Although local officials have expressed 

interest in obtaining IT tools from the departments in the short term to 

help address their IT barriers, IPO officials said their focus is on 

developing iEHR rather than implementing separate IT tools at individual 

facilities. In their view, separate interim efforts to improve the 

interoperability of facilities’ existing health IT systems would take time and 

resources away from the larger effort to replace those existing systems 

with iEHR, and it might only be beneficial to invest in local IT efforts that 

inform the IPO’s iEHR work. Until collaboration sites receive IT support 

from the departments, they will continue to face IT barriers. In addition, 

sites will continue to rely—and expend resources on—their own solutions 

 

32According to IPO officials, the iEHR effort has received about $900 million in funding 

from its inception through fiscal year 2012; in addition, the President’s budget for fiscal 

year 2013 requested $500 million in funding for iEHR.
 

Page 18 GAO-12-992 VA and DOD Collaboration

to address those barriers. Without information from the departments 

regarding the plans for iEHR—specifically, the time frame for when joint 

ventures and other collaboration sites might begin to have iEHR solutions 

implemented—local officials will not know when they could begin to see 

changes due to this new effort and be able to plan accordingly.

VA and DOD collaboration sites face a number of barriers with business 

and administrative processes that hinder collaboration and are important 

to their daily operations: reimbursement, capturing information on care 

provided to patients, credentialing of providers, and computer security 

training.

Reimbursement for services provided to patients. Aspects of the 

reimbursement process—such as assigning diagnostic and procedure 

codes to episodes of care (coding), and authorizing and paying for 

services—can pose problems, particularly when VA and DOD practices 

differ. These problems can result in inefficient workarounds at the local 

level, and difficulties such as backlogs of unpaid bills. Honolulu joint 

venture officials shared several examples of reimbursement-related 

difficulties including that the collaboration partners do not use the same 

coding and billing standards, which can lead to discrepancies that can be 

difficult to quickly resolve. Staff at DOD’s Tripler Army Medical Center 

code and bill care provided to veterans based on Military Health System 

standards, while VA staff reviewing those bills apply VA’s standards,33

Honolulu VA and DOD officials agreed that reimbursement difficulties 

have had a substantial impact on their collaboration efforts, including on 

their finances. A January 2012 Army review of billing issues at this 

collaboration site found that there was more than $20 million in bills from 

Tripler unpaid by VA for fiscal years 2009 through 2011, which included 

which can lead to difficulties reconciling the two approaches. Honolulu 

officials said that differences in how VA and DOD treat same-day 

surgeries, for example—VA considers them outpatient services while 

DOD considers them inpatient services—lead to the need to manually 

handle those bills, which takes time.

 

33Both VA and DOD use common health care coding methods when recording information 

about patient care, but the departments have their own guidance for using those codes 

and sometimes apply them differently. The codes they use include those that indicate 

types of medical procedures and diagnoses. 

Collaboration Sites’ 

Business and 

Administrative Processes
 

Page 19 GAO-12-992 VA and DOD Collaboration

bills that had not yet been processed or had been denied by VA. A July 

2011 VA coding audit of bills submitted by Tripler Army Medical Center 

stated that, as compared to VA’s coding standards, DOD’s coding was 

accurate for about 80 percent of the codes used in the sample of bills 

reviewed. The audit made recommendations to reduce the number of bills 

needing manual review and expedite VA’s payment of bills submitted by 

Tripler.34

Biloxi officials also shared examples of reimbursement issues. They 

noted that differences in VA and DOD coding practices temporarily led to 

delays in VA paying bills for care provided at Keesler Air Force Base, 

because some VA and Air Force staff involved with billing and paying for 

care were not initially familiar with the other collaboration partner’s 

reimbursement practices. In addition, they sometimes have needed to 

negotiate solutions when VA and DOD’s reimbursement practices differ.

For example, they had to agree on a reimbursement rate that would apply 

when Keesler billed VA for certain ambulatory procedures in a way that 

followed DOD guidance but was new to VA staff.

However, Honolulu VA and DOD officials did not always agree 

with each other on the specific extent or the causes of their 

reimbursement difficulties.

Honolulu and Biloxi officials have taken some steps to address problems 

with reimbursement, though difficulties remain. Honolulu officials said 

implementing an IT tool called “eDR”35

 

34Honolulu VA officials requested the audit to compare how DOD had coded the care to 

how VA would have coded the care, with the goal of identifying ways to improve the 

reimbursement process. The report noted that the audit was based on available 

documentation about patient care and that a lack of complete documentation about that 

care may have contributed to some of DOD’s codes being determined to be inaccurate. In 

August 2012, Army officials noted that the Army had recently completed a review of the 

VA audit and identified areas where they disagreed with VA’s analysis and findings. They 

said that at that time, VA and DOD officials were still in the process of responding to the 

issues raised by VA’s audit and Army’s review of it.

has improved several aspects of 

their business processes and that bills are now submitted in a faster 

automated way rather than through the time-consuming manual method 

35The Honolulu joint venture’s eDR IT tool (also known as the “enhanced Document 

Management and Referral Management” tool) is intended to improve business processes 

by facilitating the tracking and management of referrals and appointments, streamlining 

billing and payment, and allowing for data analysis, among other things. An earlier version 

of this tool was initially implemented in 2007 with an emphasis on document and referral 

management, but was enhanced in 2009 to include new components in areas such as 

billing.
 

Page 20 GAO-12-992 VA and DOD Collaboration

previously used. Biloxi officials created the Joint Venture Business Office 

to help standardize and streamline their collaboration site’s business 

processes.36

At the department level, VA and DOD officials said VA and DOD have 

taken some steps to address reimbursement issues, but that sites will still 

need to find ways to bridge VA and DOD’s differences. VA and DOD 

department-level officials have worked with Honolulu officials to address 

their difficulties. For example, a group of VA, Army, and other DOD 

officials began meeting in September 2011 to address coding issues at 

the Honolulu joint venture; as of June 2012 their work was still ongoing.

Officials reported that this office facilitates communication 

about issues such as coding and billing and helps resolve any difficulties 

that arise.

37

Capturing patient workload information. Collaboration sites sometimes 

have difficulty capturing patient workload information—the type and 

amount of care provided—which can hinder their collaboration efforts. 

Biloxi and Honolulu officials said the lack of workload information can be 

a barrier to collaboration, partly because officials use that information to 

In addition, the departments supported the eDR effort at the Honolulu 

joint venture by providing more than $3 million through JIF project 

funding. Also, VA officials told us that VA has been working since 2009 to 

implement the Intra-Governmental Payment and Collection System—a 

federal government effort to provide a standardized interagency fund 

transfer mechanism for federal agencies—which should help streamline 

how VA receives and pays bills from DOD, although it would not 

specifically address coding. Officials noted, however, that work on this 

system has been halted or delayed several times, due in part to a lack of 

funding; as of June 2012 VA officials were discussing when and how to 

proceed but no final decisions had been made. Honolulu VA officials said 

that this system would help improve their reimbursement process.

 

36The Joint Venture Business Office includes 16 staff positions—12 VA positions and 4 Air 

Force positions—to assist with functions such as authorizing episodes of care, coding, 

billing, paying bills, and analyzing data about services provided through the joint venture.

These staff are expected to improve business operations by, for example, facilitating more 

accurate coding and billing, faster and more accurate bill payment, and faster 

authorizations of services.

37DOD officials told us that while some coding difficulties occur at collaboration sites other 

than at the Honolulu joint venture, the extent of the problem in Honolulu is unique and is in 

part due to the large volume of care that the Army provides to VA at that location.
 

Page 21 GAO-12-992 VA and DOD Collaboration

evaluate and to justify the resources needed for their collaboration efforts. 

These officials also noted that workload information can affect facilities’ 

future funding. For example, leaders may be reluctant to support new JIF 

project funding for additional providers if a collaboration site’s current 

providers seem underutilized due to the lack of workload information.

Among the collaboration sites’ difficulties collecting workload information, 

Biloxi VA officials said that, until recently, they were unable to capture 

workload information when Biloxi VA surgeons treated veterans at one of 

their DOD collaboration partners—Naval Hospital Pensacola—because 

that information was not captured through the billing process or in VA’s IT 

systems. DOD has faced similar problems when its providers care for 

patients at the Biloxi VA facility. In addition, Honolulu VA officials said 

reimbursement difficulties have led to delays in getting and paying bills 

from Tripler, which has hindered their ability to capture workload 

information through the billing process in a timely way.

Biloxi and Honolulu officials have taken some steps to better collect 

workload information. Biloxi officials reported a recent approach in which 

Biloxi VA staff already located at Naval Hospital Pensacola collect 

information about the care VA surgeons provide there; that information is 

later entered into VA’s IT system. Officials said this new solution seems to 

work well, but takes time and resources, and is not as efficient as if their 

IT systems allowed an easier way to collect this information. In addition, 

some DOD providers who treat patients at the Biloxi VA facility now 

separately enter workload information into DOD’s IT system. Biloxi DOD 

officials said this solution is a work in progress, but it would be preferable 

if the IT systems allowed them to capture workload information, as some 

clinical staff have said they don’t have time for this extra data entry step.

Honolulu officials said that while they still have difficulties capturing 

workload information as quickly as they would like, that their eDR IT tool 

improved their ability to capture workload information in a more timely 

way by automating aspects of the reimbursement process.

At the department level, VA officials told us that the Intra-Governmental 

Payment and Collection System effort related to bill payment would help 

VA capture information when its providers deliver care at DOD facilities, 

so that those providers and the VA facilities can get credit for the 

workload. Honolulu VA officials said this system would improve their 

ability to collect workload information because that information would 

automatically be captured when they paid bills from DOD. As of June 

2012, there had been no DOD-wide efforts to deal with workload capture 

issues. 
 

Page 22 GAO-12-992 VA and DOD Collaboration

Dual credentialing of providers. Providers who deliver care in both VA 

and DOD facilities as part of collaboration efforts must be “credentialed” 

by both facilities. Credentialing is a process in which health care providers 

are systematically screened and evaluated for their qualifications and 

other credentials, including their licensure, education, training, and 

current competence. Biloxi and Honolulu joint venture officials said that 

the credentialing process is time-intensive and that dual credentialing 

creates some duplication of effort as staff members repeat many 

credentialing steps already completed by their collaboration partner.

Honolulu VA officials added that dual credentialing also can create delays 

between the time new providers join their facility and when they can begin 

clinical work at their collaboration partner’s facility, because the extra 

credentialing steps must first be completed. They said that it also 

complicates staffing. For example, if a dually credentialed VA social 

worker who works at Tripler Army Medical Center is on vacation or is ill, 

VA cannot send a non-dually credentialed social worker to take that 

person’s place.

At the department level, to address concerns about dual credentialing, a

Health Executive Council review resulted in a December 2010 

memorandum of understanding between VA and DOD that was intended 

to facilitate credentialing and reduce the time and costs associated with 

dual credentialing. The memorandum established guidelines for how 

credentialing information collected and verified by one department can be 

shared with the other department.38 Under these guidelines, VA and DOD 

facilities can share a range of information about providers as part of the 

credentialing process, such as details about providers’ education and 

training. However, VA and DOD facilities must still independently verify 

information that can expire or go out of date, such as providers’ licensure 

and board certification status.39

 

38The guidelines were based on standards and guidance from The Joint Commission, a 

nonprofit organization that evaluates and accredits more than 16,000 health care 

organizations in the United States, including VA medical centers and military treatment 

facilities. VA and DOD credential health care professionals in accordance with The Joint 

Commission’s credentialing standards.

Biloxi officials told us that the ability to 

use credentialing information collected by their collaboration partner has 

helped facilitate the credentialing process, but noted that there is still a 

fair amount of overlapping credentialing work to conduct. VA and DOD 

39Board certification is a process of testing and evaluation in which providers demonstrate 

to medical “boards” comprised of medical providers that they have expertise in a particular 

medical specialty, such as internal medicine, radiology, or surgery.
 

Page 23 GAO-12-992 VA and DOD Collaboration

department-level officials told us, in their view, the departments have 

done all they can to streamline dual credentialing.

Overlapping computer security training. According to VA and DOD, 

staff involved with collaboration efforts have to complete both VA and 

DOD computer security training to access both departments’ IT systems, 

which leads to some overlap in effort and loss of productivity because of 

the time it takes staff to complete the dual training. The Health Executive 

Council began work in June 2009 on a demonstration project examining 

how to reduce the overlapping mandatory training taken by VA and DOD 

staff, and selected computer security training as one of four high priority 

focus areas.

In August 2011, VA formally accepted three of the four DOD courses 

reviewed as part of this demonstration, and as a result, will grant 

reciprocity when DOD staff complete those courses and will not require 

DOD staff to take VA’s corresponding training courses.40 Although VA 

developed a strategy for implementing this decision, as of May 2012 the 

department had not made any progress in implementing the strategy, 

according to VA officials. They cited a number of delays and said that VA 

training of management staff would begin work on this effort once a 

separate VA computer security initiative had been fully implemented; 

however, they did not have an expected time frame for when 

implementation would occur. In contrast to VA, DOD decided not to grant 

reciprocity to VA staff for their VA computer security courses because, 

according to DOD, officials decided that VA’s courses were not similar 

enough to DOD’s to warrant reciprocity.

According to VA and DOD officials, the procedures DOD uses to maintain 

security at military base entrances can hinder access to medical facilities 

located on bases for veterans and those accompanying them. Base 

access procedures are critical to protecting DOD personnel and assets; 

they are established locally by military leaders at each base on the basis 

of factors such as that base’s specific security needs and guidance from 

 

40In order to be granted reciprocity by VA, DOD staff must also sign the VA National Rules 

of Behavior regarding the appropriate use and protection of information used to support 

VA missions and functions, as well as meet VA’s privacy training requirements. VA has 

decided to grant reciprocity for several DOD privacy courses, but DOD staff must take a 

gap course to cover VA-specific privacy statutes.

Accessing Medical 

Facilities on Military Bases
 

Page 24 GAO-12-992 VA and DOD Collaboration

the department and the military services. The need to ensure base 

security may add some complexity and time for veterans and their escorts 

accessing care on the base, as DOD personnel perform security checks 

as part of their base access procedures. Such procedures may include 

determining whether veterans and their escorts have sufficient 

identification, and proof of vehicle insurance and registration; as well as 

inspecting the vehicles transporting the veterans. (See fig. 4.) In some 

cases, base personnel may require veterans to provide documentation of 

their health care appointment or may conduct background screening in 

which the veteran is vetted against government databases, such as the 

National Crime Information Center.41

 

41The National Crime Information Center is a criminal justice information system 

maintained by the Federal Bureau of Investigation that contains information such as 

individuals’ criminal history records.

Access procedures can change over 

time because of changes in local military leadership, guidance, and other 

factors such as security threat levels.
 

Page 25 GAO-12-992 VA and DOD Collaboration

Figure 4: Signage at the Entrance to the Base That Houses Tripler Army Medical 

Center in Honolulu, Hawaii

Officials told us these base access procedures can take time and in some 

cases—such as during specific episodes of heightened security—may 

prevent veterans from accessing care in a timely manner. Veterans who 

are late to health care appointments due to access difficulties might be 

unable to receive care and have to return for rescheduled appointments. 

Such missed appointments can lead to lost revenue for the military 

treatment facility, which will not receive reimbursement as expected, as 

well as inefficiencies, when staff time allotted for seeing patients goes 

unused. In addition, VA department-level officials told us that base access 

issues could dissuade some local VA officials from partnering with DOD 

medical facilities. Base access procedures also can lead local officials to 

spend time and resources developing and implementing approaches to 

try to facilitate veterans’ access to care.
 

Page 26 GAO-12-992 VA and DOD Collaboration

Collaboration sites have taken some actions to mitigate the impact of 

base access procedures on veterans and their escorts and facilitate 

access to care.

• In some locations, base access issues have factored into officials’ 

efforts to build facilities on base with unique security arrangements.

For example, VA’s outpatient clinic is on the perimeter of the Navy 

base that houses Naval Hospital Pensacola, and is separated from 

the rest of the base by a security fence, which Biloxi VA and Navy 

officials said facilitates easy public access for both veterans and Navy 

personnel. Officials implemented a similar approach at Eglin Air Force 

Base, also in Florida, where a VA clinic on Air Force property is 

separated from the rest of the base by a gate that requires fingerprint 

verification to allow entry. Officials noted that while these approaches 

improve veterans’ access to these VA outpatient facilities located on 

DOD property, difficulties can still arise when veterans seek 

emergency, inpatient, or other care from the military facilities located 

on base.

• Biloxi officials started a shuttle service to transport veterans from the 

VA medical center to Keesler Air Force Base to facilitate access for 

veterans and their escorts, including those who may not otherwise 

meet certain requirements for base entry; for example, veterans and 

their escorts avoid the need to meet vehicle registration and 

inspection requirements. This shuttle, however, requires added staff 

and resources. According to officials, as a separate effort, staff call to 

remind patients of the documentation needed to access the base; 

however, patients still sometimes fail to bring the required 

documentation, which can result in extra time needed to access the 

base and sometimes lead to missed health care appointments.

• In Honolulu, Army officials decided to accept VA’s Veteran 

Identification Card42

 

42VA’s Veteran Identification Card is a card VA issues to veterans for the purpose of 

identifying veterans when they seek VA health care benefits and for assisting VA staff with 

administrative processing, though veterans are not required to have this card when they 

arrive for VA health care appointments. The card is for VA official business only and is 

issued to a veteran only after the veteran’s eligibility for VA benefits has been verified; it 

includes a color photograph of the veteran as well as the veteran’s name.

as a valid form of identification for veterans going 

to Tripler Army Medical Center for health care services, which officials 

said improved access for veterans although not their escorts. Despite 
 

Page 27 GAO-12-992 VA and DOD Collaboration

this action, it can still take a lengthy amount of time for veterans and 

their escorts to access the base because there is only one entry point 

for all individuals entering the base, including VA and DOD staff, and 

as a result long lines at the gate are common. (See fig. 5.) Honolulu 

VA officials told us that base access considerations have factored into 

their efforts to work with DOD to expand health care services through 

a new medical facility elsewhere in the community rather than by 

adding to the existing facilities on the base.43

 

43The VA Pacific Islands Health Care System is located on the base that houses Tripler 

Army Medical Center.
 

Page 28 GAO-12-992 VA and DOD Collaboration

Figure 5: Traffic Approaching the Entrance to the Base That Houses Tripler Army 

Medical Center in Honolulu, Hawaii, with the Medical Center Shown in the 

Background

Although collaboration sites have been pursuing base access solutions at 

the local level—and the departments have been aware of base access 

issues for some time—the departments recently initiated their first joint 

effort to identify potential strategies for facilitating veterans’ access to 
 

Page 29 GAO-12-992 VA and DOD Collaboration

care on military bases while also meeting base security needs, according 

to VA and DOD officials. Specifically, the Joint Chiefs of Staff initiated a 

new workgroup composed of VA and DOD officials to assess the military 

services’ current base security guidance and determine potential actions 

that could facilitate veterans’ access. As of July 2012, this workgroup had 

met once to discuss the issues and to begin its review of relevant 

guidance. One potential action the workgroup is considering is addressing 

how military bases treat the Veteran Identification Card as part of base 

access procedures. Currently, the military services have different 

guidance regarding the use of the card by veterans for base access 

purposes. VA department-level officials said that broader, more uniform 

acceptance of the card across the military services would be a useful step 

in facilitating access for veterans, but noted that it would not be a 

comprehensive solution, because it would not apply to people 

accompanying veterans to their appointments.

VA and DOD could face some difficulties identifying base access 

solutions that meet the security needs of military leadership, given the 

varied and changing security needs at the local level. However, without a 

sustained joint effort at the department level to explore ways to remove 

barriers to care across collaboration sites, veterans’ ability to access 

medical care will vary considerably. In addition, local officials will continue 

to spend time and resources developing and implementing workarounds 

to try to appropriately balance DOD’s need to maintain base security with 

veterans’ need to access care.

In addition, given the base access difficulties that can arise, it is important 

for sites to consider base access issues when they are considering new 

or expanded collaboration. Both DOD and VA department-level officials 

noted that base access is a critical consideration for collaboration efforts, 

and VA officials added that they raise the issue with local officials who are 

planning new collaborations. However, officials acknowledged that 

current guidance from both departments about VA and DOD collaboration 

efforts—such as memoranda of agreement and understanding between 

the departments, and key department-specific handbooks and 

instructions—does not explicitly address base access or encourage local 

officials to prospectively identify potential base access issues and ways to 

address them.
 

Page 30 GAO-12-992 VA and DOD Collaboration

VA and DOD department-level officials reported that several barriers 

hinder their efforts to jointly plan construction of medical facilities to serve 

both departments’ beneficiaries, and sometimes lead to missed 

opportunities to collaborate. For example, VA’s and DOD’s separate 

processes for reviewing proposed projects—including joint projects—are 

not well aligned. The processes occur on different timelines and use 

different criteria to rate and rank proposed projects, and in the past there

has been no formal mechanism for the departments to systematically 

share information to identify opportunities for joint projects, according to 

officials.44 As a result, a potential joint project may not move forward if it is 

not deemed high priority by both departments,45

Efforts to collaborate at Ft. Benning in Georgia illustrate some of the 

difficulties VA and DOD have experienced in jointly planning for 

construction of new medical facilities. Although VA and DOD officials saw 

benefits—including the opportunity to potentially save costs and improve 

patient care—to building a VA clinic that would either be part of the new 

Army hospital currently under construction at Ft. Benning or on Army 

property near the new hospital, the departments’ misaligned construction 

planning and funding processes were barriers to this effort, according to 

VA and DOD officials. Despite discussions within the departments about 

a potential joint effort at Ft. Benning, officials could not align the funding 

and approval processes for such an effort. Officials have also considered 

another option—colocating a new VA clinic with a new Army clinic 

elsewhere in the community, but have not been able to move forward with 

or when both 

departments cannot secure approval and funding for it in the same time 

frame. Further, local officials may do a substantial amount of planning for 

a project before contacting the other department about a potential 

collaboration, and by then it may be too late to collaborate as efficiently 

as possible. Officials also said that legal considerations can sometimes 

affect their joint construction efforts.

 

44VA’s Strategic Capital Investment Planning process occurs each fiscal year, takes about 

10 months to complete, and involves more than 1,000 projects, including construction 

projects, leases, and maintenance projects to meet the department’s overall needs, not 

just its medical facility needs. In contrast, DOD’s Capital Investment Decision Model 

process occurs every 18 months, takes about 16 months to complete, and involves 

roughly 60 to 80 projects to specifically meet DOD’s medical facility needs.

45VA department-level officials noted that proposed joint projects must compete with all 

other projects proposed to meet the department’s overall needs, including projects that 

address safety issues.

Joint VA and DOD 

Planning for Construction 

of Medical Facilities
 

Page 31 GAO-12-992 VA and DOD Collaboration

that option either.46 Local VA and DOD officials noted that the inability to 

build a VA clinic at the new Army hospital site or to colocate the clinics in 

the community likely reduced some opportunities to avoid costs and 

improve access to care. For example, VA officials said having a VA clinic 

at the new hospital site likely would have allowed VA and DOD to share 

the same laboratory and radiology services and could have improved 

access by having VA and DOD resources on one campus. VA 

department-level officials noted that the inability to move forward with joint 

construction at this location does not preclude local officials from 

collaborating through sharing agreements.47

As an example of how legal considerations can affect joint construction 

efforts, officials from VA in Biloxi and one of its DOD collaboration 

partners, Naval Hospital Pensacola, wanted to build a joint VA/DOD clinic 

on Navy property in Panama City, Florida, but due to legal considerations 

ultimately decided to instead build two separate clinics in close proximity. 

Specifically, officials said they changed their plans after learning that

combining VA and Navy funds for a single joint clinic would have 

exceeded VA’s statutory limit for minor construction projects because the 

total funding amount—not just VA’s contribution—would count toward the 

statutory limit.

Most recently, VA has 

explored establishing its new clinic in another location in the community, 

not colocated with the Army clinic, but as of May 2012 no final decisions 

had been made about where VA will locate its new clinic.

48

 

46Among the reasons for not colocating a VA clinic near the Army clinic, VA officials told 

us the new Army clinic’s location does not provide sufficient access to public 

transportation to meet VA’s needs.

Officials said if they had reduced the project’s scope to 

fall within VA’s minor construction limit, it would not have met their needs 

for clinical care, so they instead opted to build two separate clinics. 

Officials were not certain of the cost impact of providing services in two 

clinics rather than one, but believed doing so would be less efficient and 

potentially more costly. For example, they said a single clinic would have 

allowed for some logistical streamlining and avoided the need to duplicate 

building services like electrical utilities. The departments could have 

47There are several sharing agreements in place between the Army and its local VA 

partner at this location, according to local VA and DOD officials.

48Their plan was to use $10 million in VA funds and $2 million in Navy funds, but the total 

$12 million funding amount would have counted against the $10 million statutory limit for 

VA minor construction projects. The Navy’s corresponding minor construction limit is 

$2 million.
 

Page 32 GAO-12-992 VA and DOD Collaboration

pursued this project as a major construction project rather than as a minor 

construction project, but would have needed to obtain congressional 

authorization to do so, since major construction projects generally must

be specifically authorized by Congress. VA and DOD department-level 

officials added that potential major construction projects must compete 

internally for approval; as a result, the departments would not necessarily 

have approved this joint project to proceed as a proposed major 

construction project.

VA and DOD have taken several steps that have the potential to help 

overcome some of the departments’ differences and improve joint 

planning for medical facility construction. For example, VA and DOD 

officials participate in each other’s construction planning processes,49

 

49The participants include members of the VA/DOD Construction Planning Committee, 

which VA and DOD established in 2005 as a committee under the Joint Executive Council 

to provide a formalized structure to facilitate cooperation and collaboration in achieving an 

integrated approach to construction planning initiatives that are mutually beneficial to both 

departments. 

so 

they can provide insight on each department’s projects under 

consideration and on other potential collaboration projects; officials said 

that doing so has helped their collaboration efforts. The departments have 

also worked together on legislative proposals that, in their view, could 

enhance their ability to collaborate on joint efforts. For example, VA, in its 

fiscal year 2013 congressional budget submission, stated that it would 

propose legislative changes that would allow VA to transfer funds to—and 

receive funds from—another federal agency to use for the planning, 

design, or construction of a shared or joint medical facility, or to lease 

space for such a facility; in June 2012, VA department-level officials told 

us they were working on VA’s legislative proposal. DOD is exploring 

similar legislative changes. In addition, the departments are improving 

their information sharing to better inform their planning processes. As an 

initial step, VA and DOD department-level officials identified several types 

of data to be shared between the departments to help identify 

collaboration opportunities early in the construction planning process. As 

a result, as part of the most recent round of VA’s planning process, local 

VA officials had access to information such as DOD population and 

workload information to help them identify opportunities for joint 

construction and leasing. Department-level DOD officials said they would 

share VA population and workload data with the military services during 

the next round of DOD’s planning process as well. Officials from both 
 

Page 33 GAO-12-992 VA and DOD Collaboration

departments said they plan to build on these initial efforts by refining their 

data sharing processes. For example, officials are exploring sharing 

additional types of data to inform their departments’ construction planning 

processes and have identified the need to institute a more formalized 

process for sharing data with local officials.

VA and DOD do not have a fully developed process for systematically 

identifying opportunities for new or enhanced collaboration that could 

facilitate the departments’ shared goals of improving access, quality, and 

costs. Instead, the identification of new or enhanced collaboration 

opportunities is largely left to local medical facility leadership. Although 

the departments do have a process for jointly identifying a select number 

of sites where there are opportunities for new or expanded collaboration, 

that process does not address all options for collaboration across both 

health care systems, nor is there a requirement that the sites identified by 

that process move forward with collaboration. Until VA and DOD fully 

develop a joint process to systematically identify and pursue potential 

collaboration opportunities, the departments may miss opportunities to 

improve patients’ access to and quality of care, and to reduce costs, such 

as by addressing overlap and duplication of services that may exist 

between the two health care systems.

In our previous work on interagency collaboration,50

 

50See, for example, GAO, Interagency Collaboration: 

we reported on ways 

for agencies to facilitate and enhance their collaboration efforts, including 

ways to reduce the costly government duplication and overlap that can 

cost taxpayers billions of dollars each year. Our prior work has found that 

strategic direction is required as the basis for collaboration. As such, 

defining roles and responsibilities and mechanisms for coordination can 

help agencies clarify who will lead or participate in which activities, 

organize their joint activities and individual efforts, and facilitate decision 

making. In addition, agencies can facilitate and enhance their 

Key Issues for Congressional 

Oversight of National Security Strategies, Organizations, Workforce, and Information 

Sharing, GAO-09-904SP (Washington, D.C.: Sept. 25, 2009) and National Security: Key 

Challenges and Solutions to Strengthen Interagency Collaboration, GAO-10-822T

(Washington, D.C.: June 9, 2010).

VA and DOD Do Not 

Have a Fully 

Developed Process 

for Systematically 

Identifying New and 

Enhanced 

Collaboration 

Opportunities 
 

Page 34 GAO-12-992 VA and DOD Collaboration

collaboration efforts by establishing compatible ways of working together 

across agency boundaries.51

However, VA and DOD do not have a fully developed process and a 

sufficient strategic direction to work across agency boundaries to fully 

identify collaboration opportunities. Specifically, the departments have not 

fully developed and formalized a systematic process to review all 

possibilities for new and expanded collaboration, but instead largely leave 

the identification of new or enhanced collaboration opportunities to 

leaders at local VA and DOD medical facilities. For example, the 

decisions to pursue sharing agreements, JIF project funding, and joint 

venture status are at the discretion of local leadership. Neither 

departmental or joint VA and DOD guidance describe a systematic 

department-level process for the identification of all potential collaboration 

opportunities that may exist between the departments. DOD’s instruction 

that governs health care collaboration with VA states that the leaders of 

DOD’s military treatment facilities are to monitor emerging opportunities 

for collaboration and to conduct financial analyses and negotiate sharing 

agreements with local VA medical facilities, among other things.52

Similarly, VA’s handbook that defines procedures for health care 

collaboration with DOD medical facilities states that leadership of VA 

medical centers may decide to pursue collaboration options with DOD 

such as sharing agreements, JIF project funding, and joint venture 

status.53

While there are some positive reasons for involving local officials in 

identifying opportunities for collaboration, relying solely on local officials, 

rather than using a systematic process supported at the department level, 

can be problematic for several reasons. For example, officials from both 

Officials from the department-level VA/DOD coordination offices 

said these decisions are largely left to local leaders because they do not 

have authority over local facilities; rather they can only offer guidance. 

Further, officials said local-level officials have more direct knowledge of 

their locations, and as such, are better positioned to assess their unique 

circumstances and determine what types of collaboration make the most 

sense.

 

51GAO-06-15. 

52DOD, DOD and Department of Veterans Affairs Health Care Resource Sharing 

Program, DOD Instruction 6010.23 (Jan. 23, 2012).

53VHA, VA-DOD Direct Sharing Agreements, VHA Handbook 1660.04 (Oct. 2, 2008).
 

Page 35 GAO-12-992 VA and DOD Collaboration

departments acknowledged that collaboration is dependent on local 

leaders’ personalities and willingness to collaborate; some leaders may 

be greatly interested in exploring collaboration opportunities, while others 

may not. Moreover, given the regular changes in military treatment facility 

leadership, local leaders’ interest and commitment to collaborating can 

change over time. One additional difficulty with decisions made outside of 

a broader systematic process is that local medical facility leadership may 

not have readily available access to information necessary to examine 

what health care services could benefit from collaboration. For example, 

local leaders may not know when providing certain health care services 

through collaboration efforts rather than by purchasing care from non-VA 

or non-DOD providers would be likely to result in significant cost savings. 

Without comprehensive information on such purchased care, officials may 

be hindered in their efforts to identify areas or services that could be 

purchased from or provided to a partner facility at a lower negotiated rate, 

thus reducing costs to the federal government and possibly providing 

additional nonfinancial benefits.54

In an effort to facilitate more department-level direction and systemize the 

identification of collaboration opportunities, the departments implemented 

a process to identify a select number of sites where there are 

opportunities for new or enhanced collaboration, and designate them as 

Joint Market Opportunities (JMO) sites. However this process has 

limitations, because it does not identify all opportunities; is not formalized 

in guidance; and is not enforceable, as local officials still have discretion 

about which opportunities to pursue. Since 2009, a Health Executive 

Council work group—composed of VA and DOD department-level officials 

and representatives from the military services—has designated a few new 

JMO sites annually,

Some local officials we spoke with said 

they encountered difficulties obtaining purchased care information from 

their collaboration partner, and in one case encountered some resistance 

internally regarding sharing such information with their partner.

55

 

54VA and the Air Force routinely exchange information on such purchased care through a 

shared data system, called DataMart. Army and Navy officials have opted not to use the 

DataMart system and told us that this type of information was available to local medical 

facility leadership through financial management offices within DOD.

using criteria that have changed over time, but have 

included the proximity of VA and DOD facilities to each other, the size of 

55The most recent joint strategic plan for VA and DOD collaboration includes a goal to 

identify two new JMO sites per year. VA and DOD Joint Executive Council, Joint Strategic 

Plan Fiscal Years 2011-2013. 
 

Page 36 GAO-12-992 VA and DOD Collaboration

local VA and DOD beneficiary populations, current working relationships 

of local facility leadership, current and possible collaboration initiatives, 

and current or planned construction or renovation. This work group visits 

JMO sites to meet with local officials, explore collaboration options, and 

make recommendations about new or enhanced sharing agreements. VA 

and DOD officials define JMO sites as areas that have opportunities for 

sharing resources and risk that should be explored. Currently, the 

departments have identified 15 JMO sites.56

However, the JMO process is limited as it does not involve a systematic 

approach to reviewing and identifying all new or enhanced collaboration 

opportunities that exist. Given that only a few JMOs are identified each 

year, the departments may be missing opportunities to encourage 

collaboration at other locations. Further, officials from both departments 

stated there is no requirement that sites designated as JMOs pursue 

greater collaboration. The work group does not have the authority to 

require—or provide oversight of—implementation of their 

recommendations regarding collaboration; rather, it serves in an advisory 

and support function only. For example, Columbus, Georgia, was 

previously considered a JMO site because of potential joint construction 

between VA and the Army at Ft. Benning. An official from VA stated that 

the work group performed a site visit to examine options for collaboration 

and provide support and advice to local medical facility leadership, but 

VA’s and DOD’s construction planning processes did not align and, as we 

noted earlier, proved to be barriers to joint construction at this location.

VA officials stated the work group has not performed follow-up work to 

review ongoing collaboration at this location.

Several JMO sites have 

resulted in new or enhanced sharing agreements as an example of 

improved collaboration, according to VA and DOD officials. For example, 

the Charleston, South Carolina, area was designated as a JMO, and in 

subsequent years after designation, medical facility partners within that 

JMO jointly constructed a new facility and obtained joint venture status.

 

56The 15 JMO sites are the Gulf Coast area of Florida; Denver/Colorado Springs, 

Colorado; Bremerton/Tacoma, Washington; Central Florida area; San Antonio, Texas; 

Corpus Christi, Texas; San Diego, California; Phoenix, Arizona; Fayetteville, North 

Carolina; Oklahoma City, Oklahoma; Omaha, Nebraska; Temple/Killeen, Texas; 

Columbia, South Carolina; St. Louis, Missouri; and Guam. 
 

Page 37 GAO-12-992 VA and DOD Collaboration

Although they share a clear recognition of the potential benefit that exists 

when the departments collaborate to jointly provide health care services, 

VA and DOD may be missing additional opportunities to meet their 

shared goals of improving the access to, and the quality and costs of, 

health care, such as by reducing duplication and overlap of services. In 

particular, the departments have not taken sufficient actions to: develop 

and use performance measures to assess the effectiveness and 

efficiency of collaboration, overcome key barriers to collaboration, and 

identify new or enhanced collaboration opportunities. Specifically, the lack 

of comprehensive department-wide performance measures related to 

access, quality, and costs related to collaboration efforts may limit key 

decision makers’ ability to adequately assess the effectiveness of those 

or other future health care collaborations. Similarly, while collaboration 

sites need some flexibility to implement local solutions that best meet 

their needs, given that they have different characteristics and can 

encounter different problems, department-level efforts to address key 

barriers—such as those we identified with IT systems, business and 

administrative processes, base access, and joint planning for construction 

of medical facilities—could facilitate collaboration, as well as help reduce 

time and resources spent by local officials developing and implementing 

their own solutions. For example, additional departmental guidance about 

base access could help ensure that local officials consider these issues 

early in their discussions about new or expanded collaboration. Similarly, 

without comprehensive department-wide solutions or assistance, 

collaboration sites will continue to face significant IT challenges and 

spend resources on local solutions. Finally, VA and DOD lack a fully 

developed process for systematically identifying opportunities for new and 

enhanced collaboration; rather they largely leave such identification to 

local medical facility leadership. Without more systematic, departmentlevel approaches to collaboration in all of these areas, opportunities to 

meet their shared goals for collaboration may be out of the departments’ 

reach.

To help assess progress, identify areas for improvement, and make 

informed decisions about health care collaborations, we recommend that 

the Secretaries of Veterans Affairs and Defense 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.

Conclusions 

Recommendations for 

Executive Action
 

Page 38 GAO-12-992 VA and DOD Collaboration

To facilitate the departments’ current collaboration efforts, we recommend 

that VA and DOD systematically identify areas where department-level 

actions could help address significant barriers that hinder collaboration.

Specifically, we recommend that the Secretaries of Veterans Affairs and 

Defense take the following three actions:

• expedite and communicate a plan with time frames for when iEHR 

solutions will be made available to joint ventures and other 

collaboration sites;

• 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; and

• 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.

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.

DOD and VA each provided comments on a draft of this report. In their 

comments, both departments generally concurred with each of the 

recommendations to the Secretaries of Defense and Veterans Affairs. 

(DOD’s comments are reprinted in app. I; VA’s comments are reprinted in 

app. II.) In addition, both DOD and VA provided technical comments, 

which we have incorporated as appropriate. The departments’ specific 

responses to each of our recommendations are as follows:

Agency Comments 

and Our Evaluation 
 

Page 39 GAO-12-992 VA and DOD Collaboration

• To develop and implement a process for using performance measures 

to gauge collaboration sites’ progress in achieving goals related to 

access, quality of care, and costs, DOD and VA stated that their 2011-

2013 Joint Strategic Plan established a cost efficiency measure for 

joint venture sites and noted that the Health Executive Council plans 

to expand this cost efficiency measure and develop additional 

measures for other collaboration sites. VA stated that a Health 

Executive Council work group would develop a plan to address this 

issue within 6 months of the publication of this report.

• To expedite and communicate a plan with time frames for when iEHR 

solutions will be made available to joint ventures and other 

collaboration sites, DOD and VA stated that the IPO Advisory Board 

has approved an incremental plan for development of iEHR 

capabilities that results in achieving capabilities by the end of fiscal 

year 2017 and that the IPO will work with a Joint Executive Council 

work group to ensure stakeholders are informed of this incremental 

schedule.

• To take steps to resolve problems with collaboration sites' 

incompatible business and administrative processes, DOD and VA 

stated that the Health Executive Council will work to address issues 

related to reimbursement, workload capture, and computer security 

training. In addition, both departments indicated they will continue to 

work with The Joint Commission to address issues related to dual 

credentialing of health care providers. 

• To clarify departmental guidance regarding collaboration to include a 

discussion of base access issues that local officials should consider 

when discussing and planning collaboration efforts, DOD and VA 

stated that they will disseminate within their respective departments 

the outcomes of the joint effort to address base access. Specifically, 

DOD stated it would disseminate those outcomes to all the 

organizations within the Military Health System, and VA stated it 

would disseminate those outcomes to all VA medical facilities.

• To further develop a systematic process for identifying and furthering 

collaboration opportunities, DOD and VA stated that they would 

continue to work together to hone their joint market selection criteria 

process. Both departments generally concurred with this 

recommendation, but stressed the importance of the role of local 

leaders in the development of collaboration. Specifically, they 

emphasized that involvement of local officials is critical since they 

have the best sense of their specific health care markets, which GAO 
 

Page 40 GAO-12-992 VA and DOD Collaboration

also recognizes as an important aspect of identifying and furthering 

collaboration.

We are sending copies of this report to the Secretary of Veterans Affairs, 

Secretary of Defense, and appropriate congressional committees. In 

addition, the report is available at no charge on the GAO website at 

http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

us at (202) 512-7114 or draperd@gao.gov or (202) 512-3604 or 

farrellb@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 who made major contributions to this report are listed in 

appendix III.

Debra A. Draper 

Director, Health Care 

Brenda S. Farrell

Director, Defense Management and Capabilities
Page 41 GAO-12-992 VA and DOD Collaboration

List of Addressees 

The Honorable Tim Johnson

Chairman

The Honorable Mark Kirk

Ranking Member

Subcommittee on Military Construction, Veterans Affairs, 

 and Related Agencies

Committee on Appropriations

United States Senate

The Honorable John Culberson

Chairman

The Honorable Sanford Bishop

Ranking Member

Subcommittee on Military Construction, Veterans Affairs 

 and Related Agencies

Committee on Appropriations

House of Representatives

The Honorable Sam Farr

House of Representatives
Appendix I: Comments from the Department of 

Defense

Page 42 GAO-12-992 VA and DOD Collaboration

Appendix I: Comments from the Department 

of Defense
Appendix I: Comments from the Department of 

Defense

Page 43 GAO-12-992 VA and DOD Collaboration
Appendix I: Comments from the Department of 

Defense

Page 44 GAO-12-992 VA and DOD Collaboration
Appendix II: Comments from the Department 

of Veterans Affairs

Page 45 GAO-12-992 VA and DOD Collaboration

Appendix II: Comments from the Department 

of Veterans Affairs
Appendix II: Comments from the Department 

of Veterans Affairs

Page 46 GAO-12-992 VA and DOD Collaboration
Appendix II: Comments from the Department 

of Veterans Affairs

Page 47 GAO-12-992 VA and DOD Collaboration
Appendix II: Comments from the Department 

of Veterans Affairs

Page 48 GAO-12-992 VA and DOD Collaboration
Appendix III: GAO Contacts and Staff 

Acknowledgments

Page 49 GAO-12-992 VA and DOD Collaboration

Debra A. Draper, (202) 512-7114 or draperd@gao.gov, and 

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

In addition to the contacts named above, Lori Atkinson, Assistant 

Director; Marcia A. Mann, Assistant Director; Robin S. Burke; 

Jill K. Center; Suzanne M. Perkins; and Leigh Ann E. Sennette made 

key contributions to this report. Lisa A. Motley and Michael Willems 

provided legal support, and Jennie F. Apter assisted in report 

development.

Appendix III: GAO Contacts and Staff 

Acknowledgments 

GAO Contacts

Staff 

Acknowledgments 

(290974)
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