VA AND IHS

Further Action 

Needed to Collaborate 

on Providing Health 

Care to Native 

American Veterans

Report to Congressional Requesters

April 2013

GAO-13-354

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-354, a report to 

congressional requesters

April 2013

VA AND IHS

Further Action Needed to Collaborate on Providing 

Health Care to Native American Veterans

Why GAO Did This Study

Native Americans who have served in 

the military may be eligible for health 

care services from both VA and IHS. 

To enhance health care access and 

the quality of care provided to Native 

American veterans, in 2010, these two 

agencies renewed and revised an 

MOU designed to improve their 

coordination and resource sharing 

related to serving these veterans. GAO 

was asked to examine how the 

agencies have implemented the MOU.

This report examines: (1) the extent to 

which the agencies have established 

mechanisms through which the MOU 

can be implemented and monitored; 

and (2) key challenges the agencies 

face in implementing the MOU and the 

progress made in overcoming them. To 

conduct this work, GAO interviewed 

VA and IHS officials and reviewed 

agency documents and reports. GAO 

also obtained perspectives of tribal 

communities through attendance at 

two tribal conferences; interviews with 

tribal leaders and other tribal members, 

including veterans; and interviews with 

other stakeholders, such as health 

policy experts and consultants.

What GAO Recommends

GAO recommends that the agencies 

take steps to improve the performance 

metrics used to assess MOU 

implementation and to develop better 

processes to consult with tribes. VA 

and the Department of Health and 

Human Services agreed with these 

recommendations.

What GAO Found

The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) 

have developed mechanisms to implement and monitor their memorandum of 

understanding (MOU); however, the performance metrics developed to assess its 

implementation do not adequately measure progress made toward its goals. VA 

and IHS have defined common goals for implementing the MOU and developed 

strategies to achieve them. They have also created two mechanisms to 

implement the MOU—12 workgroups with members from both agencies to 

address the goals of the MOU, and a Joint Implementation Task Force, 

comprised of VA and IHS officials, to oversee the MOU’s implementation. These 

steps are consistent with practices that GAO has found enhance and sustain 

agency collaboration. The agencies have also developed three metrics aimed at 

measuring progress toward the MOU’s goals. However, two of the three metrics 

are inadequate because their connection to any specific MOU goal is not clear 

and, while they include quantitative measures that tally the number of programs 

and activities increased or enhanced as a result of the MOU, they lack qualitative 

measures that would allow the agencies to assess the degree to which the 

desired results are achieved. The weaknesses in these metrics could limit the 

ability of VA and IHS managers to gauge progress and make decisions about 

whether to expand or modify their programs and activities. 

VA and IHS face unique challenges associated with consulting with a large 

number of diverse, sovereign tribes to implement the MOU, and lack fully 

effective processes to overcome these complexities. VA and IHS officials told us 

the large number (566 federally recognized tribes) and differing customs and 

policy-making structures present logistical challenges in widespread 

implementation of the MOU within tribal communities. They also told us that tribal 

sovereignty—tribes’ inherent right to govern and protect the health, safety, and 

welfare of tribal members—adds further complexity because tribes may choose 

whether or not to participate in MOU-related activities. Consistent with internal 

controls, VA and IHS have processes in place to consult with tribes on MOUrelated activities through written correspondence and in-person meetings. 

However, according to tribal stakeholders GAO spoke with, these processes are 

often ineffective and have not always met the needs of the tribes, and the 

agencies have acknowledged that effective consultation has been challenging. 

For example, one tribal community expressed concern that agency 

correspondence is not always timely because it is sent to tribal leaders who are 

sometimes not the tribal members designated to take action on health care 

matters. Similarly, some tribal stakeholders told GAO that the agencies have not 

been responsive to tribal input and that sometimes they simply inform tribes of 

steps they have taken without consulting them. VA and IHS have taken steps to 

improve consultation with tribes. For example, VA has established an Office of 

Tribal Government Relations, through which it is developing relationships with 

tribal leaders and other tribal stakeholders. Additionally, in Alaska, VA has been

consulting with a tribal health organization for insight on reaching tribes. 

However, given the concerns raised by the tribal stakeholders GAO spoke with, 

further efforts may be needed to enhance tribal consultation to implement and 

achieve the goals of the MOU.

View GAO-13-354. For more information, 

contact Randall Williamson at (202) 512-7114 

or williamsonr@gao.gov.
Page i GAO-13-354 VA/IHS MOU

Letter 1 

Background 4

VA and IHS Have Developed Mechanisms to Implement and 

Monitor the MOU, but Metrics to Monitor Performance Do Not 

Adequately Measure Progress toward MOU Goals 8

VA and IHS Lack Effective Processes to Overcome the Challenges 

of Consulting with a Large Number of Diverse, Sovereign Tribes 17

Conclusions 22

Recommendations for Executive Action 22

Agency Comments 23

Appendix I Comments from the Department of Veterans Affairs 26

Appendix II GAO Contact and Staff Acknowledgments 31

Tables

Table 1: Goals and Associated Strategies in the Department of 

Veterans Affairs (VA) / Indian Health Service (IHS) 2010 

Memorandum of Understanding (MOU) 9

Table 2: Goals of Eight Workgroups Interviewed and 

Corresponding Department of Veterans Affairs (VA) / 

Indian Health Service (IHS) Memorandum of 

Understanding (MOU) Goals 11

Table 3: GAO Evaluation of Performance Metrics and Measures 

Developed to Monitor Progress toward Department of 

Veterans Affairs (VA) / Indian Health Service (IHS) 

Memorandum of Understanding (MOU) Goals 14

Contents 
Page ii GAO-13-354 VA/IHS MOU

Abbreviations

CMOP Consolidated Mail Outpatient Pharmacy

EHR electronic health record

HBPC home-based primary care

IHS Indian Health Service

MOU memorandum of understanding

NCAI National Congress of American Indians

OTGR Office of Tribal Government Relations

VA Department of Veterans Affairs

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

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

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Page 1 GAO-13-354 VA/IHS MOU

United States Government Accountability Office

Washington, DC 20548

April 26, 2013

Congressional Requesters:

Native Americans (American Indians and Alaska Natives) have 

historically served in the military at a higher rate than any other ethnic 

group, according to the Department of Defense. Once separated from the 

military, some Native American veterans are eligible to receive health 

care services from both the Department of Veterans Affairs (VA) and the 

Indian Health Service (IHS), an agency within the Department of Health 

and Human Services.1

To improve the health status of Native American veterans through 

coordination, collaboration, and sharing of resources among VA, IHS, and 

tribes, in 2010, VA and IHS expanded upon a 2003 memorandum of 

understanding (MOU). This 2010 MOU outlined mutual goals for the 

agencies’ collaboration and coordination of resources and care in 

providing health care services to Native American veterans. For example, 

it included provisions for joint contracts and purchasing agreements, 

sharing staff, ensuring providers in VA and IHS could access the 

electronic health records of shared patients, and the development of 

payment and reimbursement policies and mechanisms to support care 

delivered to Native American veterans eligible for care in both systems. 

In a May 2012 congressional hearing, both VA and IHS reported that they 

have taken steps to collaborate to improve access to and quality of health 

care services for Native American veterans.2 However, questions have 

been raised by members of Congress about the extent of collaboration 

between the two agencies. For example, a 2012 Senate report noted that 

stronger partnerships among VA, IHS, and tribally operated health 

facilities are essential to ensuring Native American veterans have access 

to health care services.

3

 

1

According to the U.S. Census Bureau, in 2011 approximately 150,000 individuals 

identified themselves as Native American veterans. This includes only individuals who 

identified as American Indian or Alaska Native alone and not in combination with another 

racial group. Therefore, it likely underestimates the number of Native American veterans.

We were asked to examine how the agencies 

2

Oversight Hearing on Programs and Services for Native Veterans: hearing before the 

Committee on Indian Affairs, United States Senate, 112th Cong (May 24, 2012).

3

S. Rep. No. 112-168, at 45 (May 22, 2012).

 
 

Page 2 GAO-13-354 VA/IHS MOU

have implemented the MOU. In this report, we address the (1) extent to 

which VA and IHS have established mechanisms through which the MOU 

can be effectively implemented and monitored; and (2) key challenges 

that VA and IHS face in implementing the MOU, and the progress they 

have made in overcoming them.

To address both of these objectives, we reviewed the MOU and 

documentation related to the MOU’s implementation, including periodic 

updates and descriptions of sharing agreements. We also reviewed the 

signed reimbursement agreement between VA and IHS as well as signed 

reimbursement agreements between VA and tribes.4 We interviewed VA 

and IHS officials, including VA’s Director of the Office of Rural Health and 

Office of Tribal Government Relations, the IHS Chief Medical Officer, and 

leaders of 8 of 12 VA/IHS workgroups tasked with addressing and 

implementing the MOU to learn about the steps that have been taken to 

implement and monitor the MOU and any related challenges. We 

selected these eight workgroups because they were involved in 

addressing issues regarding agency coordination and sharing resources.5

To assess the MOU’s implementation and related challenges, we took 

several actions to obtain the views of tribal communities. We attended a 

VA tribal consultation on MOU implementation at the National Indian 

Health Board Consumer Conference in Denver, Colorado, in September 

2012, and attended the National Congress of American Indians (NCAI) 

Annual Conference in Sacramento, California, in October 2012. At the 

NCAI conference, we conducted listening sessions for tribal members to 

solicit their views on MOU implementation. We also interviewed various 

other tribal health representatives outside of the listening sessions and 

 

4

VA is required to reimburse federally and tribally operated facilities for health care 

services provided to beneficiaries who are eligible for such services from VA. 25 U.S.C. 

§ 1645(c).

5

The eight workgroups we interviewed were: (1) Coordination of Care; (2) Health 

Information Technology; (3) System Level; (4) Payment and Reimbursement; (5) Sharing 

of Care Process, Programs and Services; (6) Training and Recruitment; (7) Oversight; and 

(8) Alaska. VA and IHS count the Training and Recruitment Workgroup as two separate 

workgroups. However, because these two workgroups share similar goals, an IHS official 

told us they combined them into one workgroup, and for the purposes of this report we 

considered them as one workgroup. There are also four other workgroups covering: 

(1) Services and Benefits, (2) New Technologies; (3) Cultural Competency and 

Awareness; and (4) Emergency and Disaster Preparedness. We did not interview these 

workgroups because they did not directly relate to our objectives.
 

Page 3 GAO-13-354 VA/IHS MOU

the conferences. In all, we interviewed 34 tribal members and other 

representatives (collectively referred to in this report as tribal 

stakeholders), including tribal leaders, tribal veterans, tribal health 

directors and administrators, and tribal health policy experts and 

consultants. The tribes represented in our interviews were geographically 

varied, including representation from 9 IHS Areas and 10 Veterans 

Integrated Service Networks and included representation from tribes that 

varied in size from approximately 500 members to 310,000 members. We 

cannot generalize findings from these interviews as representative of all 

tribal communities; however, we believe that patterns or issues identified 

in these interviews may illustrate issues that other tribes face as well.

To evaluate the extent to which VA and IHS have established 

mechanisms through which the MOU can be effectively implemented and 

monitored, we assessed this evidence against relevant criteria from our 

past work on interagency collaboration, practices from leading resultsoriented public-sector organizations, and agency strategic planning.6 To 

evaluate key challenges that VA and IHS face in implementing the MOU, 

and the progress they have made in overcoming them, we assessed this 

evidence against internal controls.7

We conducted this performance audit from July 2012 to April 2013 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.

 

6

GAO, Results-Oriented Government: Practices That Can Help Enhance and Sustain 

Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: Oct. 21, 2005); 

Managing for Results: Key Considerations for Implementing Interagency Collaborative 

Mechanisms, GAO-12-1022 (Washington, D.C.: Sept. 27, 2012); Executive Guide: 

Effectively Implementing the Government Performance and Results Act, 

GAO/GGD-96-118 (Washington, D.C.: June 1996); and Agencies’ Strategic Plans Under 

GPRA: Key Questions to Facilitate Congressional Review, GAO/GGD-10.1.16

(Washington, D.C.: May 1997).

7

GAO, Internal Control Standards: Internal Control Management and Evaluation Tool, 

GAO-01-1008G (Washington, D.C.: August 2001).
 

Page 4 GAO-13-354 VA/IHS MOU

While Native American veterans are geographically dispersed throughout 

the United States, the West and South regions contain the majority of the 

Native American veteran population, according to Census data. Some 

Native American veterans are members of the 566 federally recognized 

tribes that are distinct, independent political communities that possess 

certain powers of self-government, which we refer to as tribal sovereignty. 

Specifically, federally recognized tribes have government-to-government 

relationships with the United States, and are eligible for certain funding 

and services provided by the United States. In addition, some Native 

American veterans are members of the more than 400 Indian groups that 

are not recognized by the federal government (which we refer to in this 

report as non–federally recognized tribes).8 Many—but not all—Native 

American veterans are dually eligible for health care services in VA and 

IHS. For example, a veteran who is a member of a non–federally 

recognized tribe may be eligible for VA health care services, but would 

not be eligible for IHS health care services.9

VA is charged with providing health care services to the nation’s veterans, 

and estimates that it will serve 6.3 million patients in fiscal year 2013. 

VA’s fiscal year 2012 budget for medical care was approximately 

$54 billion. The department provides health care services at VA-operated 

facilities and through agreements with non-VA providers.

10

 

8

For more information on federal funding for non–federally recognized tribes, see GAO, 

Indian Issues: Federal Funding for Non-Federally Recognized Tribes, 

Veterans who 

served in the active military, naval or air service and who were discharged 

or released under conditions other than dishonorable are generally 

eligible for VA health care.

GAO-12-348

(Washington, D.C.: Apr. 12, 2012).

9

To be eligible for IHS health care services, an individual must be closely affiliated with a 

federally recognized tribe, as evidenced by such factors as membership; enrollment; 

residence on tax-exempt land; ownership of restricted property; active participation in 

tribal affairs; or other relevant factors indicative of Native American descent. See 

42 C.F.R. § 136.12.

10To manage its provision of health care services for eligible veterans, VA operates a 

system of annual patient enrollment in accordance with eight listed priorities. See 

38 U.S.C. § 1705.

Background 

Native American Veteran 

Demographics

VA and IHS Structure and 

Benefits 
 

Page 5 GAO-13-354 VA/IHS MOU

IHS is charged with providing health care to the approximately 2.1 million 

eligible Native Americans. IHS’s fiscal year 2012 budget for medical care 

was approximately $3.9 billion. Similarly to VA, IHS provides health care 

services at IHS-operated facilities through direct care and pays for 

services from external providers through contract health services. In 

addition to IHS-operated facilities, some federally recognized tribes 

choose to operate their own health care facilities, which receive funding 

from IHS.11 Like their IHS-operated counterparts, tribally operated 

facilities provide direct care services and pay for contract health services. 

IHS also provides funding through grants and contracts to nonprofit urban 

Native American organizations through the Urban Indian Health program 

in order to provide health care services to Native Americans living in 

urban areas.

In 2003, VA and IHS signed an MOU to facilitate collaborative efforts in 

serving Native American veterans eligible for health care in both systems. 

In 2010, the agencies developed a more detailed MOU to further these 

efforts. The 2010 MOU contains provisions related to several areas of 

collaboration, including actions related to the following:

• Joint contracts and purchasing agreements: Development of 

standard, preapproved language for inclusion of one agency into 

contracts and purchasing agreements developed by the other agency; 

and processes to share information about sharing opportunities in 

early planning stages.

• Sharing staff: Establishment of joint credentialing and privileging, 

sharing specialty services, and arranging for temporary assignment of 

IHS Public Health Service commissioned officers to VA.

 

11Under the Indian Self-Determination and Education Assistance Act, as amended, 

federally recognized tribes can enter into self-determination contracts or self-governance 

compacts with the Secretary of Health and Human Services to take over administration of 

IHS programs for Native Americans previously administered by IHS on their behalf 

because of their status as Indians. Self-governance compacts allow tribes to consolidate 

and assume administration of all programs, services, activities, and competitive grants 

administered throughout IHS, or portions thereof, that are carried out for the benefit of 

Native Americans because of their status as Indians. Self determination contracts allow 

tribes to assume administration of a program, programs, or portions thereof. See 

25 U.S.C. §§ 450f(a) (self-determination contracts)and 458aaa-4(b)(1) (self-governance 

compacts).

VA and IHS Collaboration 

through Memorandums of 

Understanding 
 

Page 6 GAO-13-354 VA/IHS MOU

• Electronic Health Record (EHR) access: Establishment of standard 

mechanisms for VA providers to access records in IHS and tribally 

operated facilities, and vice versa, for patients receiving care in both 

systems. 

• Reimbursement: Development of payment and reimbursement 

policies and mechanisms to support care delivered to dually eligible 

Native American veterans.

Executive Order 13175, issued on November 6, 2000, required federal 

agencies to establish regular and meaningful consultation and 

collaboration with Indian tribe officials in the development of federal 

policies that have tribal implications.12 IHS issued a tribal consultation 

policy in 2006 to formalize the requirement to seek consultation and 

participation by Indian tribes in policy development and program activities. 

According to the policy, IHS will consult with Indian tribes to the extent 

practicable and permitted by law before any action is taken that will 

significantly affect Indian tribes. In November 2009, a Presidential 

Memorandum directed federal agencies to develop plans, after 

consultation with Indian tribes and tribal officials, for implementing the 

policies and directives of Executive Order 13175.13 VA’s plan included 

development of a tribal consultation policy, which the agency released in 

February 2011. VA’s tribal consultation policy asserts that VA will 

establish meaningful consultation to develop, improve, or maintain 

partnerships with tribal communities. The policy states that consultation 

should be conducted before actions are taken but acknowledges there 

may not always be “sufficient time or resources to fully consult” on an 

issue.14

 

12Federal agencies are required to consult with Alaska Native corporations on the same 

basis as Indian tribes under Executive Order 13175. Pub. L. No. 108-199, div. H, § 161, 

118 Stat. 3, 452 (2004), as amended. 

13See 74 Fed. Reg. 57,881 (Nov. 9, 2009).

14According to the policy, the principal focus of consultation is the tribally designated 

“tribal official” and that consultation will be initiated by means of written notification.

VA and IHS Tribal 

Consultation Policies
 

Page 7 GAO-13-354 VA/IHS MOU

In past work we have reported on key practices to enhance and sustain 

interagency collaboration15

• agreeing on roles and responsibilities;

including

• establishing compatible policies, procedures, and other means to 

operate across agency boundaries; and

• developing mechanisms to monitor, evaluate, and report on results.

Additionally, our past work has identified a range of mechanisms that the 

federal government uses to lead and implement interagency 

collaboration.16 We found that regardless of the mechanisms used, there 

are key actions the government can take, including (1) having clear goals; 

(2) ensuring relevant participants are included in collaboration; and 

(3) specifying the resources—human, information, technology, physical, 

and financial—needed to initiate or sustain the collaboration. We have 

also found in past work on leading public-sector organizations and 

agency strategic planning that it is important to (1) define clear missions 

and desired outcomes; (2) use performance measures that are tangible, 

measurable, and clearly related to goals to gauge progress; and (3) use 

performance information as a basis for decision making.17 Finally, internal 

control standards emphasize the importance of effective external 

communications that occur with groups that can have a serious effect on 

programs, projects, operations, and other activities, including budgeting 

and financing.18

 

15GAO-06-15 and GAO-12-1022. 

16GAO-12-1022. 

17GAO/GGD-10.1.16 and GAO/GGD-96-118 (for this report, GAO studied a number of 

leading public-sector organizations that were successfully becoming more resultsoriented, including state governments such as in Florida, Texas, and Virginia; and foreign 

governments such as in Australia and the United Kingdom). 

18GAO-01-1008G. 

Best Practices and Internal 

Control Standards for 

Interagency Collaboration 

and Performance 

Monitoring 
 

Page 8 GAO-13-354 VA/IHS MOU

VA and IHS have documented common goals in their MOU, created 

12 workgroups that are tasked with developing strategies to address the 

goals of the MOU, and created a Joint Implementation Task Force to 

coordinate tasks, develop implementation policy, and develop 

performance metrics and timelines—actions that are consistent with those 

we have found enhance and sustain agency collaboration. However, most 

of the performance metrics developed by VA and IHS to monitor the 

implementation of the MOU need to be more clearly related to the goals 

of the MOU in order to allow the agencies to gauge progress toward MOU 

goals.

Consistent with our past work on practices that can enhance and sustain 

collaboration, VA and IHS have defined common goals for implementing 

the MOU and developed specific strategies the agencies plan to take to 

achieve them. Table 1 summarizes the five goals in the 2010 MOU and 

selected strategies for implementing them.

VA and IHS Have 

Developed 

Mechanisms to 

Implement and 

Monitor the MOU, but 

Metrics to Monitor 

Performance Do Not 

Adequately Measure 

Progress toward MOU 

Goals 

VA and IHS Have Defined 

Common Goals and 

Created Mechanisms to 

Implement the MOU
 

Page 9 GAO-13-354 VA/IHS MOU

Table 1: Goals and Associated Strategies in the Department of Veterans Affairs (VA) / Indian Health Service (IHS) 2010 

Memorandum of Understanding (MOU)

MOU goal Selected strategies to achieve goal

1. Increase access to and improve quality of health care and 

services to the mutual benefit of both agencies. Effectively 

leverage the strengths of the VA and IHS at the national and 

local levels to afford the delivery of optimal clinical care.

• Share specialty services

• Develop joint credentialing and privileging of staff

• Develop joint training initiatives

• Develop and implement new models of care using new 

technologies, including telehealth services

2. Promote patient-centered collaboration and facilitate 

communication among VA, IHS, Native American veterans, 

tribal facilities, and Urban Indian Clinics.

• Establish mechanism to share electronic health records for 

patients receiving care in both systems and from tribally 

operated facilities

• Improve the delivery of care through sharing of care 

processes, programs, and services (for example, posttraumatic stress disorder and diabetes management)

3. In consultation with tribes at the regional and local levels, 

establish effective partnerships and sharing agreements 

among VA headquarters and facilities, IHS headquarters and 

IHS, tribal, and Urban Indian Health programs in support of 

Native American veterans.

• Develop standard preapproved language for inclusion of one 

agency into the other agency’s existing contracts

• Develop preapproved templates for agreements to facilitate 

local, regional, and national collaboration 

4. Ensure that appropriate resources are identified and available 

to support programs for Native American veterans.

• Develop payment and reimbursement policies and 

mechanisms for veterans receiving care in both systems

5. Improve health promotion and disease prevention services to 

Native Americans to address community-based wellness.

• Improve the delivery of care through sharing of care 

processes, programs, and services (for example, posttraumatic stress disorder and diabetes management)

Source: GAO analysis of information provided by VA and IHS.

VA and IHS have created two mechanisms to implement the MOU—

workgroups and a Joint Implementation Task Force. We have reported 

that MOUs are most effective when they are regularly updated and 

monitored, actions that can be achieved by workgroups and task forces.19

VA and IHS created 12 workgroups tasked with responsibility for 

implementing and developing strategies to address the goals of the MOU, 

such as interoperability of health information technology; developing 

payment and reimbursement agreements; and sharing of care processes, 

programs, and services.20

 

19

Each workgroup includes members from VA 

GAO-12-1022. 

20The 12 workgroups are: (1) Coordination of Care; (2) Health Information Technology; 

(3) System Level; (4) Payment and Reimbursement; (5) Sharing of Care Process, 

Programs and Services; (6) Training and Recruitment; (7) Oversight; (8) Alaska; 

(9) Services and Benefits; (10) New Technologies; (11) Cultural Competency and 

Awareness; and (12) Emergency and Disaster Preparedness.

Workgroups
 

Page 10 GAO-13-354 VA/IHS MOU

and IHS, a step that can foster mutual trust across diverse agency 

cultures and facilitate frequent communication across agencies to 

enhance shared understanding of collaboration goals, according to our 

previous work on interagency collaboration. According to VA and IHS 

officials, most of the workgroup members volunteered to serve on the 

workgroups and were self-selected, and VA officials told us that they have 

consulted with tribes on how to increase tribal participation in the 

workgroups. The agencies also told us that some workgroup members

were asked to participate because of their subject-matter expertise.21

Goals established by each workgroup appear to be aligned with MOU 

goals. Specifically, all eight of the workgroups we interviewed described 

goals that were consistent with the MOU goals.22 Table 2 lists each 

workgroup we interviewed and provides a crosswalk between workgroup 

goals and the corresponding MOU goal or strategy.

 

21The officials told us that in cases where a workgroup lacks authority to implement an 

MOU task, workgroup members would notify MOU coordinators designated by each 

agency, who would then notify the appropriate agency officials about the issue.

22We did not interview 4 workgroups because they did not directly relate to our objectives: 

(1) Services and Benefits; (2) New Technologies; (3) Cultural Competency and 

Awareness; and (4) Emergency and Disaster Preparedness.
 

Page 11 GAO-13-354 VA/IHS MOU

Table 2: Goals of Eight Workgroups Interviewed and Corresponding Department of Veterans Affairs (VA) / Indian Health 

Service (IHS) Memorandum of Understanding (MOU) Goals

Workgroup Goals Crosswalk to MOU goals

Coordination of Care • Increase access to and quality of care.

• Promote patient-centered collaboration and 

increase coordination of care, including 

comanagement of dual- eligible veterans. Work 

with tribal urban organizations.

Goal 1: Increase access to and improve quality of 

health care and services to the mutual benefit of both 

agencies.

Goal 2: Promote patient- centered collaboration and 

facilitate communication.

Health Information 

Technology

• Improve care through the development of 

health information technology.

• Establish system to share electronic health 

records.

Goal 1: Increase access to and improve quality of 

health care and services to the mutual benefit of both 

agencies.

Goal 2: Promote patient-centered collaboration and 

facilitate communication.

System Level • Plan and implement system-level resources to 

share information about contracts and 

purchasing arrangements.

Goal 3: Establish effective partnerships and sharing 

agreements.

Goal 4: Ensure that appropriate resources are 

identified and available to support programs.

Payment and 

Reimbursement

• Design system to ensure VA and IHS systems 

are compatible for the billing and collecting 

process under contracts or agreements. 

Goal 4: Ensure that appropriate resources are 

identified and available to support programs.

Sharing of Care 

Process, Programs and 

Services

• Several MOU goals, including improving access 

to and quality of care for post-traumatic stress 

disorder among Native American veterans.

• Conduct outreach to tribal areas in areas such 

as public health and suicide prevention.

• Develop and update suicide prevention training.

• Provide IHS pharmacists access to VA 

programs to streamline pharmacy dispensing 

activities.

• Coordinate and collaborate to improve the lives 

of elderly and frail Native Americans, and 

increase access to VA’s home-based primary 

care program.

Goal 1: Increase access to and improve quality of 

health care and services to the mutual benefit of both 

agencies.

Goal 2: Promote patient- centered collaboration and 

facilitate communication.

Goal 3: Establish effective partnerships and sharing 

agreements.

Goal 5: Improve health-promotion and diseaseprevention services to Native Americans to address 

community-based wellness.

Training and 

Recruitment

• Increase capability and improve quality through 

training and workforce development, sharing of 

educational and training opportunities, and the 

development of joint training initiatives.

• Increase access to care through sharing of staff 

and enhanced recruitment and retention of 

professional staff.

Goal 1: Increase access to and improve quality of 

health care and services to the mutual benefit of both 

agencies.
 

Page 12 GAO-13-354 VA/IHS MOU

Workgroup Goals Crosswalk to MOU goals

Alaska • Increase access to services and benefits of IHS 

and VA.

• Improve coordination of care, including 

comanagement, for Native American veterans 

served by both VA and tribal organizations.

• Increase availability of services, in accordance 

with law, by the development of payment and 

reimbursement policies and mechanisms.

Goal 1: Increase access to and improve quality of 

health care and services to the mutual benefit of both 

agencies.

Goal 2: Promote patient- centered collaboration and 

facilitate communication.

Goal 3: Establish effective partnerships and sharing 

agreements

Goal 4: Ensure that appropriate resources are 

identified and available to support programs.

Goal 5: Improve health-promotion and diseaseprevention services to Native Americans to address 

community-based wellness.

Oversight • Set priorities for the Joint Implementation Task 

Force to identify the strategies and plans for 

accomplishing the tasks and aims of the MOU, 

and help the task force follow the strategy and 

plans of the MOU.

• Meet with and receive updates from other 

workgroups and elevate issues identified by the 

workgroups.

• Develop reports on progress in implementing 

the MOU.

Goal 1: Increase access to and improve quality of 

health care and services to the mutual benefit of both 

agencies.

Goal 2: Promote patient- centered collaboration and 

facilitate communication.

Goal 3: Establish effective partnerships and sharing 

agreements.

Goal 4: Ensure that appropriate resources are 

identified and available to support programs.

Goal 5: Improve health-promotion and diseaseprevention services to Native Americans to address 

community-based wellness.

Source: GAO evaluation of interviews with workgroups and agency officials and the MOU.

VA and IHS created the Joint Implementation Task Force to oversee the 

overall implementation of the MOU. This task force comprises officials 

from both agencies including from the Office of the Secretary of Veterans 

Affairs, the IHS Chief Medical Officer, and the director of VA’s Office of 

Tribal Government Relations, and is scheduled to meet quarterly. It 

develops implementation policy and procedures for policy-related issues 

identified by the workgroups; creates performance metrics and timelines, 

evaluates progress; and compiles an annual report on progress in MOU 

implementation. Creating a mechanism, such as a task force, intended 

not only to address issues arising from potential incompatibility of 

standards and policies across agencies but also to monitor, evaluate, and 

report on MOU results, can help to facilitate collaboration, according to 

our previous work on interagency collaboration.

Joint Implementation Task 

Force
 

Page 13 GAO-13-354 VA/IHS MOU

The process developed by the Joint Implementation Task Force to 

monitor the implementation of the MOU includes obtaining data on three 

performance metrics; however, two of the three metrics do not allow the 

agencies to measure progress toward the MOU’s goals. Our previous 

work has found that successful performance metrics should be tangible 

and measureable, clearly aligned with specific goals, and demonstrate 

the degree to which desired results are achieved.23 Although all three of 

the performance metrics are tangible and measurable, only one is also 

clearly aligned with a specific goal and defined in a manner that would 

allow the agencies to adequately measure the degree to which desired 

results are achieved. The other two metrics are inadequate because their

connection to a specific goal is not clear and they lack qualitative 

measures that would allow the agencies to measure the degree to which 

desired results are achieved. For example, one MOU goal is to increase 

access to and improve quality of health care services, but none of the 

metrics mention any targets specifically linked to increased access or 

improved quality of care. Another goal is to establish effective 

partnerships and sharing agreements among the agencies and the tribes 

in support of Native American veterans. Although one of the metrics 

appears to be related to this goal, in that it is focused on measuring the 

number of outreach activities that are a result of partnerships, it lacks 

measures to determine how well the outreach activities are meeting the 

goal of establishing effective partnerships or other potential goals to 

which the outreach may contribute, such as facilitating communication 

among VA, IHS, veterans, and tribally operated facilities. The metrics 

would therefore not enable VA and IHS to determine how well these 

specific goals are being achieved. Table 3 describes the performance 

metrics and performance measures and our evaluation of them.

 

23GAO/GGD-96-118 and GAO/GGD-10.1.16. 

VA and IHS Performance 

Metrics Do Not Adequately 

Measure Progress on the 

MOU Goals
 

Page 14 GAO-13-354 VA/IHS MOU

Table 3: GAO Evaluation of Performance Metrics and Measures Developed to Monitor Progress toward Department of 

Veterans Affairs (VA) / Indian Health Service (IHS) Memorandum of Understanding (MOU) Goals

Metric Measures GAO evaluation

Metric 1: Programs increased 

or enhanced as a result of the 

VA-IHS MOU

1. Number of programs enhanced and increased

2. Number of events and activities to increase or 

enhance the programs

3. Number of veterans impacted

4. Met purposes of MOU (yes or no)

5. Met intent of MOU (yes or no)

6. Level of VA-IHS-Tribal participation (poor, fair, 

good, excellent)

Inadequate

Tangible and measurable, but not clearly 

aligned with an MOU goal and would not 

allow agencies to determine how well MOU 

goals are achieved.

Metric 2: Outreach activities 

that are the result of MOU 

partnerships

1. Types of outreach events held

2. Number of outreach events held

3. Number of veterans and others (families, 

caregivers) impacted

4. Met purposes of MOU (yes or no)

5. Met intent of MOU (yes or no)

6. Level of VA-IHS-Tribal participation (poor, fair, 

good, excellent)

Inadequate

Tangible and measurable but not clearly 

aligned with an MOU goal, and would not 

allow agencies to determine how well MOU 

goals are achieved.

Metric 3: Development of 

reimbursement agreements 

and sharing agreements as a 

result of the MOU

1. Number of sharing agreements developed

2. Number of tribes impacted

3. Number of reimbursement agreements developed

4. Number of tribes impacted

5. Met purposes of MOU (yes or no)

6. Met intent of MOU (yes or no)

7. Level of VA-IHS-Tribal participation (poor, fair, 

good, excellent)

Adequate

Tangible and measureable, aligned with an 

MOU goal, and allows the agencies to 

measure progress toward goals three and 

four.

Source: GAO analysis of information provided by VA and IHS.

Note: The five MOU goals are:

(1) Increase access to and improve quality of health care and services to the mutual benefit of both 

agencies. Effectively leverage the strengths of the VA and IHS at the national and local levels to 

afford the delivery of optimal clinical care.

(2) Promote patient-centered collaboration and facilitate communication among VA, IHS, Native 

American veterans, tribal facilities, and Urban Indian Clinics.

(3) In consultation with tribes at the regional and local levels, establish effective partnerships and 

sharing agreements among VA headquarters and facilities, IHS headquarters and IHS, tribal, and 

Urban Indian Health programs in support of Native American veterans.

(4) Ensure that appropriate resources are identified and available to support programs for Native 

American veterans.

(5) Improve health promotion and disease prevention services to Native Americans to address 

community-based wellness.

Using these metrics, the agencies have issued MOU progress reports, 

but the metrics included in the reports generally are not clearly tied 

specifically to the goals of the MOU, nor do they allow the agencies to 
 

Page 15 GAO-13-354 VA/IHS MOU

determine how well MOU goals have been achieved. Leading publicsector organizations have found that metrics that are clearly linked to 

goals and allow determination of how well goals are achieved are key 

steps to becoming more results-oriented. For example: 

• According to the agencies’ fiscal year 2011-2012 metrics report,24 for 

Metric 1 (programs increased or enhanced as a result of the MOU), 

more than 15 programs were enhanced or increased as the result of 

the MOU, and 440 events and activities occurred that increased or 

enhanced the programs. The report then provides examples of 

programs that have been enhanced, such as a care coordination 

program in which a registered nurse “works with Indian Health, Tribal 

Programs, and other agencies and hospitals through direct meetings 

at various facilities to ensure communication and improved care.” 

However, the report does not always describe information that would 

allow the agencies to determine how well each activity contributes to 

meeting MOU goals. For instance, in the description of an enhanced 

care coordination program noted above, the report does not indicate 

how the agencies determined that communication has improved 

among participants. Absent this information, it is not clear how the 

agencies could draw conclusions about whether improved 

communication has actually been facilitated and therefore how well 

the activity contributed to meeting the MOU goal of promoting patientcentered collaboration and facilitating communication.

• According to the metrics report, for Metric 2 (outreach activities 

increased or enhanced as a result of MOU partnerships), eight types 

of activities were increased or enhanced. However, the report lists 

only seven types of outreach and does not include enough information 

to determine how well the outreach contributes to meeting MOU 

goals. For example, one outreach activity cited in the report, 

“Outreach to promote implementation of new technologies,” includes 

the activity “VA Office of Telehealth Services (OTS) Coordinator 

participated in Web-ex sessions with IHS on use of technology to 

improve patient care.” Although not stated in the report, this activity 

appears to help implement the MOU strategy of enhancing access 

through the development and implementation of new models of care 

using new technologies, including telehealth, related to the MOU 

 

24Department of Veterans Affairs and Indian Health Service, Department of Veterans 

Affairs (VA) Indian Health Service (IHS) Memorandum of Understanding (MOU) Metrics 

Report—Fiscal Year (FY) 2011/2012.
 

Page 16 GAO-13-354 VA/IHS MOU

goals of promoting patient-centered care and increasing access to 

care. However, while outreach activities are measurable and tangible, 

and might help to achieve goals of the MOU, the report does not state 

how the agencies will determine whether the sessions actually were 

effective in improving patient care or increasing access, information 

that is necessary to allow the agencies to tell how well the activity 

helps achieve the MOU goals.

• For each metric, the agencies report whether the activities “met the 

purpose of the MOU,” “met the intent of the MOU,” and whether the 

“level of VA-IHS-Tribal participation” was poor, fair, good, or excellent. 

While determining whether the agencies’ activities meet the purpose 

and intent of the MOU is a critical step, and obtaining tribal 

participation is consistent with MOU goals, the report does not 

describe how these determinations were made. Agency officials told 

us that these determinations were made subjectively by each 

workgroup while keeping in mind the goals and strategies in the MOU.

The weaknesses we found in these performance metrics could limit the 

ability of VA and IHS managers to gauge progress and make decisions 

about whether to expand or modify programs or activities, because the 

agencies will not have information on how well programs are supporting 

MOU goals. VA and IHS officials told us that they developed these 

performance metrics because the initial performance metrics, drafted by 

the workgroups themselves and other VA and IHS staff, varied in quality. 

The three metrics and measures were intended to provide some simple, 

measurable ways for workgroups to report on their progress. However, 

they also acknowledged that there were weaknesses in the measures 

and told us that refining these performance metrics is a priority. According 

to the officials, they plan to revise workgroup metrics by April 2013 and on 

a continuous basis going forward. In doing so, they plan to consult 

subject-matter experts and existing VA and IHS performance metrics, for 

example, prevention of hospital admissions in home-based primary care 

programs.
 

Page 17 GAO-13-354 VA/IHS MOU

Mainly because of the large number of diverse tribal communities and 

tribal sovereignty, VA and IHS face unique challenges associated with 

coordinating and communicating to implement the MOU. VA and IHS 

have processes in place for consulting with tribes, but these measures fall 

short in several respects and do not ensure such consultation is effective.

VA and IHS officials told us the large number (566) of federally 

recognized tribes and differing customs and policy-making structures 

present logistical challenges in widespread implementation of the MOU 

within tribal communities.25

In addition, VA and IHS officials noted that tribal sovereignty further adds 

to the logistical complexity of the efforts of the agencies to implement the 

MOU. Tribal sovereignty includes the inherent right to govern and protect 

the health, safety, and welfare of tribal members. Indian tribes have a 

For instance, according to some VA officials, 

in some tribes as a matter of protocol, an agency must be invited on tribal 

lands or be sponsored by a council member in order to address a tribal 

council. Such a policy could add administrative processes that might 

delay implementation and require greater sensitivity from agency officials, 

adding to the challenge of consulting with tribes. As another example, the 

title or position of the tribal person designated to make decisions 

regarding health care may differ from tribe to tribe, complicating the 

decision-making process among VA, IHS, and tribes. VA officials told us 

in some tribes, for example, a tribal leader may have several roles, only 

one of which is making decisions on health care, whereas in other tribes 

there may be a tribal health director whom the tribal leader has 

designated to manage health care in the tribal community. Potentially, 

these differences can affect the speed and degree at which collective 

decisions can be made.

 

25In addition to the federally recognized tribes, there are more than 400 non–federally 

recognized tribes. Although these non–federally recognized tribes may not receive IHS 

funding and members may not be eligible for IHS services, VA has an obligation to serve 

their members who are eligible for VA services.

VA and IHS Lack 

Effective Processes to 

Overcome the 

Challenges of 

Consulting with a 

Large Number of 

Diverse, Sovereign 

Tribes 

VA and IHS Face 

Challenges Implementing 

the MOU Related to the 

Large Number of Diverse, 

Sovereign Tribes
 

Page 18 GAO-13-354 VA/IHS MOU

legal and political government-to-government relationship with the federal 

government, meaning federal agencies interact with tribes as 

governments, not as special interest groups or individuals. VA and IHS 

officials told us that because of tribal sovereignty, tribally operated 

facilities may choose whether or not to participate in a particular 

opportunity for collaboration related to the MOU, which makes it 

challenging to achieve some of the goals of the MOU. VA and IHS can 

inform tribes of an opportunity but cannot require them to participate. For 

example:

• In order to meet the MOU goal to establish standard mechanisms for 

access to electronic health record (EHR) information for shared 

patients, VA and IHS have coordinated to adapt their information 

technology systems to allow them both to participate in the eHealth 

Exchange, a national effort led by the Department of Health and 

Human Services for sharing EHR information.26 However, EHR 

workgroup members told us that some tribally operated facilities have 

opted to use an off-the-shelf product in place of the IHS system, which 

the workgroup members do not have the resources to support.

• In another instance, as a part of their efforts to meet the MOU goal to 

establish effective partnerships and sharing agreements, VA and IHS 

are working to implement VA’s Consolidated Mail Outpatient 

Pharmacy (CMOP) throughout IHS. Workgroup members assigned to 

these activities said they plan to implement the program in all IHSoperated facilities by spring 2013 but cannot require tribally operated 

facilities to participate. Some smaller tribal communities with more 

limited postal access are not interested in using the CMOP program, 

according to the workgroup members.

 

26The eHealth Exchange is a set of standards, services, and policies that enable the 

secure exchange of health information over the Internet.
 

Page 19 GAO-13-354 VA/IHS MOU

VA and IHS communicate MOU-related information with the tribes 

through written correspondence, in-person meetings, and other steps, as 

is consistent with internal controls calling for effective external 

communications with groups that can have a serious effect on programs 

and other activities; however, according to tribal stakeholders we 

interviewed, these methods for consultation have not always met the 

needs of the tribal communities, and the agencies have acknowledged 

that effective consultation has been challenging.

VA and IHS send written correspondence (known as “Dear Tribal Leader” 

letters) regarding the MOU to tribal communities. However, the agencies 

have acknowledged that because of the large and diverse nature of the 

tribes, they have struggled to reach the tribal member designated to make 

health care decisions with information about the MOU. Both VA officials 

and members of tribal communities told us that, because tribal leaders 

are not always the tribal person designated to make decisions regarding 

health care, the “Dear Tribal Leader” letters may not always make their 

way to tribal members designated to take action on health care matters.

VA officials told us that their formal consultation is conducted with tribal 

leaders. However, these officials also noted that, in addition to the letters 

sent to tribal leaders, they have a network of contacts within each tribe 

that includes, among others, tribal health directors, and this network 

receives concurrent notice of communication with tribal leaders via 

conference calls, listservs, and newsletters. IHS officials said sometimes, 

in addition to the tribal leader, they may also send letters to, or otherwise 

communicate directly with, tribal health program directors if they know of 

them. However, they also noted they do not maintain a specific record—

such as a listserv—of tribal health program directors. Without reaching 

the tribal members responsible for decision-making on healthcare 

matters, VA and IHS may not always be effectively communicating with 

tribes about the status of the MOU and its related activities nor be 

obtaining tribal feedback that is critical with respect to implementation of 

the MOU.

Likewise, seven tribal stakeholders we spoke with noted similar concerns 

regarding the “Dear Tribal Leader” letters as VA and IHS. For example, 

one tribal stakeholder said letters should go to a specific person, such as 

a tribal health director, to ensure that the information is seen by the right 

people in a timely manner. It may take the tribes time to pass along letters 

sent only to tribal leaders to the tribal health director or other appropriate 

people, by which point any deadlines included in the correspondence 

could be missed. Once the information has reached the tribal leader, 

VA and IHS Processes in 

Place to Overcome the 

Complexities Associated 

with Consulting with 

Tribes Do Not Always 

Ensure Effective 

Consultation 

Written Correspondence
 

Page 20 GAO-13-354 VA/IHS MOU

tribes bear the responsibility to ensure it is passed on to the appropriate 

audience in a timely manner.

Another specific concern tribal stakeholders that we spoke with 

expressed relating to written correspondence was that the agencies 

sometimes use the letters to simply inform them of steps the agencies 

have taken without consulting the tribes, as called for by the agencies’ 

tribal consultation policies. For example, some tribal stakeholders said VA 

and IHS did not include them in the original development of the 2010 

MOU, even though the goals and activities in the MOU could directly 

affect them. According to 10 of the tribal stakeholders we spoke with, 

tribes should have been included in developing the MOU, which 

addresses proposed plans, policies, and programmatic actions that may 

affect tribes. For example, the MOU seeks to improve delivery of health 

care by developing and implementing new models of care using new 

technologies, including telehealth services such as telepsychiatry. 

Instead, the agencies solicited tribal comments after the agencies had 

signed the MOU. According to two tribal stakeholders, the agencies were 

not responsive to the comments provided on the MOU. One stakeholder 

said their comments were not acknowledged upon receipt nor did IHS 

ever follow up on the issues raised by their comments. The stakeholder 

suggested IHS designate a point person to track feedback and ensure 

follow-up. VA and IHS officials told us that they did not hold tribal 

consultation meetings before the signing of the MOU because they 

viewed the MOU as an agency-to-agency agreement rather than as an 

agreement between the agencies and the various tribes.

VA and IHS officials said they hold quarterly meetings with tribal 

communities and also attend events, such as conferences held by Native 

American interest organizations. Three tribal stakeholders told us that 

when the agencies have held consultation meetings, the meetings are not 

interactive enough—stating that agency officials speak for the majority of 

the time—and that VA does not provide enough information prior to these 

meetings. These tribal stakeholders said providing information ahead of 

time could allow tribes to better prepare for meetings, discuss issues as a 

tribe beforehand, and determine which tribal members should attend. If 

tribal officials with the authority and desire to work with VA and IHS do not 

receive needed information on opportunities because of an ineffective 

consultation process, local facility leadership may not have readily 

available access to information necessary to examine which collaborative 

opportunities are present, and thus VA and IHS may be hindered in their 

efforts to coordinate health care for Native American veterans.

In-person Meetings 
 

Page 21 GAO-13-354 VA/IHS MOU

VA and IHS are undertaking other efforts designed to enhance 

consultation with tribes. These include the following steps:

• In January 2011, VA established the Office of Tribal Government 

Relations (OTGR) to serve as the point of contact for tribes. According 

to VA officials, this office conducted four consultation meetings in 

2012 and employed five field staff to help manage communication 

with tribal communities and to work with IHS on local MOU 

implementation efforts.

• In February 2011, VA released the agency’s tribal consultation policy. 

VA officials said they are developing a report that will explain the 

process for evaluating comments from tribes and making decisions 

based on them. The officials expect the report to be released to the 

public in the spring of 2013.

• The agencies have made more local efforts to communicate with 

tribes, which have led to some success. For example, agency officials

and tribal stakeholders noted that the workgroup assigned to 

implement MOU activities in Alaska used successful methods for 

working with tribes. The Alaska workgroup told us they cultivated a 

relationship with an Alaskan tribal health organization in order to get 

advice on the appropriate customs for consulting with individual tribes 

there. In addition, the workgroup said they scheduled consultation 

meetings in conjunction with other meetings, which would limit the 

amount of travel tribal community members would need to undertake. 

VA employees also took cultural awareness training, and VA officials 

visited Alaska to demonstrate the agency’s dedication to providing 

care to Native American veterans, which, according to the workgroup, 

led to buy-in from tribal communities. VA and Alaskan tribes have 

signed 26 reimbursement agreements.

Some tribal stakeholders that we spoke with have acknowledged the 

steps taken by the agencies thus far as positive but in some cases 

expressed concerns regarding tribal consultation. In the case of the tribes 

working with the Alaska workgroup, one stakeholder praised VA’s efforts 

to work with tribal health organizations to communicate with tribes. In 

another example, two tribal stakeholders said they approved of OTGR’s 

establishment as an office dedicated to Native American veterans’ issues. 

However, four tribal stakeholders expressed concerns that, despite the 

creation of OTGR, VA still has not always been effective in its efforts to 

consult with tribes or be responsive to tribal input provided during 

consultation. For example, one stakeholder questioned whether 
 

Page 22 GAO-13-354 VA/IHS MOU

consultation was done with every tribe and described VA’s consultation 

process as sporadic. This stakeholder’s concern implies that VA’s

outreach efforts may not be systematically reaching all tribal communities.

However, VA officials told us that, in addition to issuing notices in the 

Federal Register and Dear Tribal Leader letters, they have a systematic 

process of hosting training summits for tribes and scheduling regular 

conference calls and presentations to tribal leadership. In another 

instance, one tribal community member said OTGR lacks—and thus 

cannot disperse to tribes—the technical knowledge necessary for tribes to 

partner with VA on activities such as negotiating reimbursement 

agreements. VA officials noted that OTGR staff may not always be 

technical experts on a given topic but said they are able to identify those 

experts and play a key role in linking tribes with them.

Coordination between VA and IHS is essential to ensuring that highquality health care is provided to dually eligible Native American veterans. 

While the 2010 MOU includes common goals that should facilitate agency 

coordination, and the agencies have created workgroups tasked to 

implement the MOU, we found that a critical mechanism for monitoring 

the implementation of the MOU, the agreement’s performance metrics, 

has weaknesses. Specifically, the inadequacies we found in performance 

metrics could limit the agencies’ ability to measure progress towards 

MOU goals and ultimately make decisions about programs or activities.

Overcoming the challenges related to working with a large number of 

diverse, sovereign tribes is also essential to successfully achieving the 

goals of the MOU. Although steps have been taken to consult with tribes 

regarding the MOU and related activities, consultation has not always 

been effective in assuring that the people designated to make health care 

decisions in each tribe are reached and tribes are included in planning 

and implementation efforts. Ineffective consultation with tribal 

communities could delay or limit potential VA, IHS, and tribal community 

partnerships to achieve the goals of the MOU and could hinder agency 

efforts to gain support for MOU activities and address the health care 

needs of Native American veterans.

To ensure the health care needs of Native American veterans are 

addressed most efficiently and effectively, we recommend that the 

Secretary of Veterans Affairs and Secretary of Health and Human 

Services take the following two actions:

Conclusions 

Recommendations for 

Executive Action
 

Page 23 GAO-13-354 VA/IHS MOU

• As the agencies move forward with revising the MOU’s performance 

metrics and measures, ensure that the revised metrics and measures 

allow decision makers to gauge whether achievement of the metrics 

and measures supports attainment of MOU goals.

• Develop processes to better ensure that consultation with tribes is 

effective, including the following:

• A process to identify the appropriate tribal members with whom to 

communicate MOU-related information, which should include 

methods for keeping such identification up-to-date.

• A process to clearly outline and communicate to tribal 

communities the agencies’ response to tribal input, including any 

changes in policies and programs or other effects that result from 

incorporating tribal input.

• A process to establish timelines for releasing information to tribal 

communities to ensure they have enough time to review and 

provide input or, in the case of meetings, determine the 

appropriate tribal member to attend the event.

We provided draft copies of this report to VA and the Department of 

Health and Human Services for review. Both agencies concurred with our 

recommendations. In addition, VA provided us with comments on the 

draft report, which we have reprinted in appendix I, as well as general and 

technical comments, which were incorporated in the draft as appropriate.

We are sending copies of this report to appropriate congressional 

committees; the Secretary of Veterans Affairs; the Secretary of Health 

and Human Services; and other interested parties. In addition, the report 

is available at no charge on the GAO Web site at http://www.gao.gov. 

Agency Comments
 

Page 24 GAO-13-354 VA/IHS MOU

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

me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs are on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix II. 

Randall Williamson

Director, Health Care
Page 25 GAO-13-354 VA/IHS MOU

List of Requesters

The Honorable Patty Murray

Chairman

Committee on the Budget

United States Senate

The Honorable Bernie Sanders

Chairman

Committee on Veterans’ Affairs

United States Senate

The Honorable Mark Begich

United States Senate

The Honorable Jon Tester

United States Senate
Appendix I: Comments from the Department of 

Veterans Affairs

Page 26 GAO-13-354 VA/IHS MOU

Appendix I: Comments from the Department 

of Veterans Affairs
Appendix I: Comments from the Department of 

Veterans Affairs

Page 27 GAO-13-354 VA/IHS MOU
Appendix I: Comments from the Department of 

Veterans Affairs

Page 28 GAO-13-354 VA/IHS MOU
Appendix I: Comments from the Department of 

Veterans Affairs

Page 29 GAO-13-354 VA/IHS MOU
Appendix I: Comments from the Department of 

Veterans Affairs

Page 30 GAO-13-354 VA/IHS MOU
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 31 GAO-13-354 VA/IHS MOU

Randall Williamson, (202) 512-7114 or williamsonr@gao.gov

In addition to the contact named above, Gerardine Brennan, Assistant 

Director; Jennie Apter; Lori Fritz; Hannah Marston Minter; and Lisa Motley 

made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(291054)
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