Health Care Access: Improved Oversight, Accountability, and Prioritization Can Improve Access for Native American Veterans
Published: 2014-06-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Native Americans who have served in the military may be eligible for health care services from both VA and IHS, but according to reports some have had problems accessing care. In 2010 these two agencies expanded upon an MOU designed to improve Native American veterans' access to care at their facilities. GAO was asked to examine how the MOU has increased access to care.
This report examines: (1) the actions that VA and IHS have taken to implement the provisions in the 2010 MOU related to access to care for Native American veterans, and (2) what is known about how access to care for Native American veterans has improved. To conduct this work, GAO reviewed agency documents and VA and IHS reimbursement data and interviewed VA and IHS officials. GAO also visited three sites selected to reflect geographic variation to learn about access to care locally through interviews with regional VA and IHS officials, health facility officials, and Native American veterans and their tribal representatives. GAO also contacted other individuals who help Native American veterans seek enrollment in the VA to obtain their insights about improvements in access to care.
section_title: What GAO Found
paragraphs: The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) have taken a variety of actions to improve access to care for Native American veterans under their 2010 memorandum of understanding (MOU); however according to stakeholders, these agencies face substantial implementation challenges. VA and IHS have taken actions to (1) strengthen outreach and enrollment through information sharing and training; (2) expand services through national and local projects; (3) increase training about cultural competency for staff at VA and IHS facilities; and (4) establish reimbursement agreements that allow VA to reimburse IHS facilities for services provided to veterans. However, in each of these areas challenges remain, such as insufficient data to identify Native American veterans for outreach, obstacles to reaching those who live in very remote areas, and technological challenges such as lack of Internet connectivity or phone lines.
While VA and IHS have taken actions to increase access, the oversight, accountability, and prioritization of MOU implementation are lacking. Specifically:
Oversight is inconsistent: In 2013, the officials tasked with oversight of the implementation of the MOU did not meet and did not systematically evaluate the progress of MOU implementation.
Written policies and guidance are lacking: According to officials, the only documentation outlining the procedures to report VA and IHS progress on implementation efforts is contained in a set of training slides used in a December 2012 training session, and these slides have not been formalized in written policy or guidance.
Prioritization of MOU implementation is lacking: Leadership of VA and IHS have not made MOU implementation a priority, which threatens the ability of the two agencies to move forward in implementing the MOU. Key officials attributed this, in part, to their perception that their non-MOU related responsibilities had a higher priority.
Without consistent oversight, formal policy or guidance on responsibilities for MOU implementation, and the prioritization of MOU implementation, VA and IHS leadership do not have reasonable assurance that the objectives of the MOU related to access to care are being addressed.
Native American veterans and their representatives that GAO contacted reported mixed views on whether access to care has improved over the past 3 years. Although a majority reported that access to care had improved, others either said that that they did not think it had improved or were unsure. For example, 53 of 102 Native American veterans representatives GAO contacted reported that in the last 3 years there had been an increase in the number of Native American veterans accessing health care at VA or IHS-funded facilities; however, 12 felt there had been no change, and 36 said they did not know.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA and IHS establish written policy or guidance designating specific roles and responsibilities for agency staff to hold leadership accountable and improve implementation and oversight of the MOU. VA and IHS agreed with GAO's recommendation.

section_title: Letter
paragraphs: Native Americans historically have 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 (HHS).
IHS-funded facilities include both facilities that are operated by the IHS and tribal health  program (THP) facilities that are funded by IHS, but operated by the tribes.
Hearing on VA and Indian Health Service Cooperation: Hearing Before the Committee on  Veterans’ Affairs, United States Senate, 111th Cong (November 5, 2009). veterans to access certain types of care at IHS-funded facilities. Further,  it has been reported that many Native American veterans live in very rural  areas and have difficulty obtaining transportation to both VA and IHS- funded facilities, or face very long travel times to facilities, which can  make it difficult to access care at either type of facility.
In 2010, VA and IHS expanded upon a 2003 memorandum of  understanding (MOU), which included provisions to improve Native  American veterans’ access to VA and IHS facilities and the agencies’  coordination of efforts related to the MOU. The 2010 MOU, which aimed  to more fully address the core access problems for Native American  veterans, includes goals to increase access to health care services for  Native American veterans. It also describes strategies intended to  achieve this goal. For example, the 2010 MOU includes provisions for  expanding outreach through the Tribal Veterans Representative Program,  expanding telehealth services, developing payment and reimbursement  policies and mechanisms to support care delivered to Native American  veterans eligible for care in both systems, and providing training to VA  and IHS staff on the agencies’ eligibility requirements.
We previously reported on the agencies’ coordination of efforts related to  the MOU. We examined the extent to which the agencies established  mechanisms for MOU implementation and monitoring, the key challenges  the agencies faced in implementing the MOU, such as the challenge of  coordinating with a large number of unique tribes, and the progress made  in overcoming those challenges.
We were asked to report on the extent to which the MOU has increased  access to care for Native American veterans. This report examines:   (1) the actions that VA and IHS have taken to implement the provisions in  the 2010 MOU related to access to care for Native American veterans;  and (2) what is known about how access to care for Native American  veterans has improved.
To examine the actions that VA and IHS have taken to implement  provisions in the 2010 MOU related to access to care for Native American  veterans, we collected information from a variety of sources. We reviewed  a broad range of documents related to MOU activities, such as quarterly  reports that describe MOU-related activities and progress by VA and IHS.  We reviewed information and data related to reimbursement by VA to  IHS-funded facilities for services provided to Native American veterans.  We interviewed agency officials, including leaders of 5 of the 12 work  groups that were established to implement the MOU, about actions they  have taken to increase access to care, monitor progress, and assess  outcomes in improving access. Finally, we conducted site visits to three  regions of the country—the Upper Peninsula of Michigan, Northern  Arizona, and Alaska—to learn about actions taken by VA and IHS to  improve access to care at the local level. The regions were selected to  reflect geographic variation, variation in the types of VA and IHS-funded  facilities available, and the presence or absence of reimbursement  agreements between the VA and IHS-funded facilities. We conducted  interviews with: VA and IHS regional officials; VA, IHS, and tribal health  facility staff such as administrators, enrollment coordinators, and business  office managers; and representatives of tribes. Information obtained  through these site visits cannot be generalized to the nationwide Native  American veteran population.
To examine what is known about how access to care for Native American  veterans has improved, we interviewed Native American veterans and  their representatives—such as Tribal Veterans Representatives (TVR)— in 12 interviews during our three site visits. We analyzed this information  to determine the extent to which there were positive or negative  comments related to changes in access to care for Native American  veterans—such as whether interviewees thought that the number of  Native American veterans obtaining care at VA or IHS facilities had  increased or decreased. We used the following convention to state  whether comments were made at most, many, some, or few of these  interviews: most—at least one comment in 9 to 11 interviews; many—at  least one comment in 5 to 8 interviews; some—at least one comment in 3  to 4 interviews; and few—at least one comment made in 1 to 2 interviews.  We also obtained views from an additional 102 representatives of Native  American veterans through a Web-based questionnaire.questionnaire included questions about the extent to which access to care  for Native American veterans had changed during the past 3 years. The  responses to this questionnaire are not generalizable to the entire  population of representatives of Native Americans.
We conducted this performance audit from June 2013 to June 2014 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.
subsections: section_title: Background
subsections: section_title: Native American Veterans
paragraphs: 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.
section_title: VA and IHS Structure and Benefits
paragraphs: VA is charged with providing health care services to the nation’s eligible  veterans, and served 6.5 million individual patients in fiscal year 2013. In  fiscal year 2013, VA had $56 billion in appropriations available for medical  care. VA’s health care system includes 21 regional networks—Veterans  Integrated Service Networks (VISN)—to which each of VA’s 151 medical  centers are assigned. The VA medical centers offer a variety of inpatient  and outpatient services, ranging from routine examinations to complex  surgical procedures. VA’s health care system also includes facilities such  as community-based outpatient clinics. Eligibility for VA health care is  based on several factors, including the veteran’s period of active service,  discharge status, the presence of service connected disabilities or  exposures, income, and other factors such as status as a former prisoner  of war. In addition, VA categorizes eligible veterans into eight priority  groups, and some veterans may be responsible for co-payments.
IHS was established for the purpose of providing, or arranging for, health  care to the approximately 2.2 million eligible Native Americans. IHS’s  fiscal year 2013 budget was approximately $4.1 billion. While IHS’s  headquarters is based in the Washington, D.C., area, overall the agency  is organized into 12 federally designated geographic service areas that  cover all or part of 35 states. IHS provides health care services directly  through a system of about 120 facilities that are operated by IHS— including hospitals, health clinics, and health stations. In addition to IHS- operated facilities, some federally recognized tribes choose to operate  their own health care facilities—tribal health programs (THPs)—that  receive IHS funding. THPs operate the majority of facilities funded by  IHS, including 500 facilities, such as hospitals, clinics and health stations.  IHS also provides funding to nonprofit, urban Native American  organizations through the Urban Indian Health program to provide health  care services to Native Americans living in urban areas. To be eligible for  IHS health care services, an individual must be a person of Indian  descent belonging to the Indian community, 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   In instances where a Native American veteran is eligible for a  factors.particular health care service from both VA and IHS, VA is the primary  payer.
section_title: Memorandum of Understanding
paragraphs: 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, VA and IHS replaced the MOU with an updated MOU, which  outlines specific goals and strategies related to increasing access to care  for Native American veterans, such as goals to improve outreach and  cultural competency, expand services including through telehealth, and  develop payment and reimbursement policies. Specifically, the MOU  included the following provisions related to access to care: providing training for IHS and tribal staff on VA and IHS eligibility  requirements to assist them with appropriate referrals for services; expanding the TVR program, which uses Native American liaisons to  conduct outreach to tribes to assist with veterans’ eligibility questions;  increasing cultural awareness and culturally competent care; developing and implementing telehealth services such as  telepsychiatry and telepharmacy; and  increasing the availability of services by developing payment and  reimbursement policies and mechanisms.
The MOU provides for a broad range of collaboration between VA and  IHS. One goal of the MOU is to bring together strengths and expertise  from each agency to improve both the care and services provided by  each organization.
VA and IHS designated certain staff to implement the MOU. The two key  offices within VA that have been involved in implementing the MOU are  the Office of Rural Health (ORH) and the Office of Tribal Government  Relations (OTGR). VA created ORH in 2007 to focus on better serving  the needs of veterans residing in geographically remote areas through a  combination of community-based clinic expansions, increased  partnerships with non-VA providers, and increased use of telehealth   VA established OTGR in 2011 to work to strengthen and  services.enhance partnerships that enhance access to services and benefits for  Native American veterans. Within IHS, MOU responsibilities have been  delegated to the Chief Medical Officer and staff.
To accomplish the goals set forth in the MOU, VA and IHS created  interagency work groups, tasked with implementing and developing  strategies to address the goals of the MOU, such as developing payment  and reimbursement policies and mechanisms, and developing and  implementing new models of care through new technology, including  telehealth services. Each work group includes staff from VA and IHS, and, in some cases, tribal representatives. In many cases, work group  members volunteered to serve on the work groups. The goals established  by each work group align with MOU goals.
One of the work groups, referred to as either the Leadership work group  or the Joint Implementation Task Force, is responsible for the oversight  and the overall implementation of the MOU, and charged with identifying  strategies and plans for accomplishing the goals of the MOU. It includes  officials from both agencies, including from the Office of the Secretary of  Veterans Affairs, the IHS Chief Medical Officer, and the director of OTGR,  and also includes the co-chairs of certain MOU work groups. The  agencies defined responsibilities for the Joint Implementation Task Force.  Specifically, it is charged with developing implementation plans and  procedures for policy-related issues identified by the work groups,  creating performance metrics and timelines, collecting quarterly progress  reports from the work groups and from other sources such as VA VISN  Native American Inventory reports, evaluating progress, identifying  priority action items for work groups, and providing an annual report on  progress in MOU implementation. According to the MOU 2012 Annual  Report, the Joint Implementation Task Force is expected to meet  quarterly.
section_title: Actions VA and IHS Have Taken to Improve Access to Care for Native American Veterans Face Implementation Challenges, and Oversight and Accountability Are Lacking
paragraphs: VA and IHS staff have taken actions to improve access to care, including  strengthening outreach and enrollment efforts, expanding services  offered, increasing efforts to improve cultural competency, and  implementing reimbursement agreements. However, according to various  stakeholders, these efforts face a variety of implementation challenges,  such as a lack of data identifying which Native Americans are veterans,  difficulty reaching Native American veterans who live in remote locations,  and staff turnover at IHS and THP facilities. In addition, although VA and  IHS have identified procedures for collecting information on the various  actions taken by VA and IHS facilities to address the goals of the MOU,  the agencies lack a defined approach to effectively track and oversee  implementation of the MOU.
subsections: section_title: VA and IHS Have Taken Actions to Improve Access to Care, but Implementation Challenges Limit Their Effectiveness
paragraphs: In four main areas, VA and IHS have taken actions to improve access to  care for Native American veterans: (1) outreach and enrollment,   (2) expanded services including telehealth, (3) training and improvement  in cultural competency, and (4) reimbursement agreements. However, in  each of these areas, unresolved challenges prevent these actions from  being fully or effectively implemented.
subsections: section_title: Information Sharing, Training, and Outreach about Enrollment Have Improved, but Sufficient Information to Identify Native Americans and Resources to Help Them Are Lacking
paragraphs: Both agencies have taken actions to improve outreach to Native  American veterans and to provide information about enrollment into the  VA health system. Specifically, IHS and VA have developed various ways  to share information about eligibility and enrollment and VA has  conducted a variety of training programs about these topics.
Information sharing: IHS and VA have supported information  sharing in a variety of ways with tribes, IHS and THP facilities, and  Native American veterans. For example, OTGR published a monthly  newsletter focusing on resources available to tribes to promote  enrollment in the VA health system. In addition, IHS officials in two of  our three site visit areas reported that they organized introductions of  VA staff to tribal officials and IHS and THP facility staff, and the VA  medical centers in all of these site visit areas reported that they  shared information in a variety of ways such as health benefit fairs  held at tribal locations, regular conference calls with tribal health  officials, and meetings with Native American veterans’ organizations.  In the Native American Inventory quarterly reports, 20 of 21 VISNs  reported one or more information sharing activities, such as making  presentations to tribal elders and providing information at tribal health  fairs.
Training: VA and IHS conducted a variety of training activities about  eligibility and enrollment. VA holds monthly on-line training about the  enrollment process that is available for staff at IHS and THP facilities  and for representatives of Native American veterans. In partnership  with IHS, VA funded multiple regional training events designed to  increase knowledge of VA benefits, eligibility criteria, and the  enrollment process. Participants in these events included tribal health  officials, IHS and THP facility staff, TVRs, and members of Native  American veteran military organizations. Facilities in two of our three  site visit locations also reported conducting training activities. For  example, at one of the sites we visited, IHS provided training to staff  at its facilities about VA health benefits and services. In another site  visit area, VA officials reported that they recruited and trained over  190 TVRs from 2010 through 2013.
Although VA and IHS have undertaken a variety of outreach efforts,  officials from VA, IHS, and THP facilities identified two main ongoing  challenges to implementing effective outreach to Native American  veterans—the lack of available data to identify eligible Native American  veterans and insufficient agency resources to effectively conduct  outreach in rural areas.
Lack of available data: VA and IHS headquarters officials, as well as  local facility officials in all three of our site visit areas, reported that it is  difficult to conduct outreach to Native American veterans because  there is limited data identifying who they are. While officials reported  that IHS health registration forms include a question about whether  the patient is a veteran, officials indicated that patients are not  required to report this information. While officials at some IHS and  THP facilities with whom we met said they have taken actions to  identify veterans in their tribes, others lack such data. An official at  one THP facility, for example, said that veteran status data had not  been collected from their patients; officials at another THP reported  that without a list identifying who is a veteran, it is difficult to conduct  outreach and enroll veterans in the VA. Similarly, while VA registration  forms include a question about race/ethnicity, VA officials reported  that VA facilities have not required veterans to report whether they are  Native American, and this limits VA’s ability to conduct outreach to  Native American veterans.
Insufficient resources for effective outreach to very rural areas:  VA, IHS and THP officials, and TVRs reported that there are  insufficient resources—such as outreach volunteers and funding for  travel—for effective outreach to the remote areas where many Native  American veterans live. For example, officials at one THP that serves  an area of approximately 75,000 square miles, including terrain that  requires travel by boat or plane, reported that they were not aware of  any TVRs serving their region. Officials at another THP said that there  was a lack of funding for TVRs to travel to conduct outreach.
section_title: More Health Services Are Now Available to Native American Veterans, but Further Progress Has Been Slowed by Technical Issues and Delays in Finalizing Service Expansion Agreements
paragraphs: Actions taken by VA and IHS to expand health care services for Native  American veterans include funding for service expansion, a national effort  to increase telehealth connections between VA and IHS, and local efforts  to expand health services through satellite and mobile services and  through telehealth.
Funding for service expansion: Since the MOU was signed, both  agencies have sponsored funding to support the expansion of health  services. Specifically, ORH awarded about $1.8 million in funding  from 2012 through 2014 for five telemental health projects for eligible  veterans in Native American communities, including the development  and operation of programs in certain areas of Alaska, Michigan, and  Oklahoma; and IHS provided financial support to enable the  expansion of three THP clinics in Alaska, Mississippi, and Oklahoma  in 2011.
National effort to expand telehealth consultation between VA and  IHS: Officials from the MOU work group that promotes new  technology reported that VA and IHS are in the process of completing  activities designed to improve the connectivity between VA and IHS  required for live telehealth consultation. VA officials reported that as of  April 2014, the testing phase was nearing completion. According to  VA officials, the next step is the development of business plans by  individual IHS facilities to establish collaborative telehealth programs  with VA. This work group has also identified opportunities for  collaboration between the two agencies, specifically on teleretinal  services for diabetes care.
Local efforts to expand services and telehealth: Data gathered  from our site visits and our review of the quarterly VISN reports for  2013 identified a number of local efforts to expand the availability of  health care services. For example, in one area, officials reported that  the local VA medical center expanded services to Native American  veterans in one location by renting space from a THP to provide  onsite health services to eligible Native American veterans; further, it  was seeking agreements with two THPs to establish VA-provided  telehealth services. According to VA and IHS officials at another site  we visited, the local VA medical center and an IHS facility  collaborated to establish a VA primary care presence at the IHS  facility. This VA medical center also initiated similar plans to partner  with another IHS facility and two THP facilities, established a mobile  clinic that serves eligible veterans on Native American reservations,  and added telehealth services to its community based outpatient  clinics that serve Native American veterans. In the quarterly Native American Inventory reports submitted to VA by VISNs, 14 of 21 VISNs  listed one or more efforts to expand telehealth services for Native  American veterans in their region.
Agency officials and staff at VA, IHS, and THP facilities described three  main challenges that need to be addressed to better ensure the  successful implementation of expansion efforts: (1) the lack of  interoperability between VA and THP computer systems; (2) a lack of  technical resources; and (3) delays in finalizing service expansion  agreements.
Incompatible systems: Agency officials said that while VA and IHS  facilities have been working on connectivity between their VA and IHS  platforms for telehealth, THPs may use different computer systems  than IHS; therefore, connectivity between VA and THPs has to be  tested and explored on a case-by-case basis. This can slow  collaboration on telehealth services, and tribes that do not use the IHS  or VA platform would need to obtain the necessary technology. For  example, in one site visit area, integration of THP and VA telehealth  has been challenged by differences in technical connectivity and  information security policies. Since a majority of IHS-funded facilities  are operated by THPs, the potential for collaboration on telehealth  services may be limited by the interest and resources available from  tribes for this purpose.
Insufficient technical resources: According to facility officials in all  three site visit areas, the lack of technical resources in some rural  locations has hampered the expansion of telehealth or other services  such as home-based health. For example, in one area, tribal health  officials said that there was no infrastructure to support telehealth  services. Also in this area, VA medical center officials said that they  explored expanding virtual care through the use of veterans’ home  computers but found that some veterans lack phone lines or adequate  Internet connectivity. In another area, THP facility officials said that  there was poor Internet “bandwidth” in their area that reduced the  quality of transmission for telehealth
Delays in finalizing agreements to expand services: Agency and  facility officials from two of our three site visit areas reported that it  can take years to finalize service expansion agreements between VA  and IHS or THP facilities, which could limit incentives to pursue such  agreements. There were several examples cited in which it took 3  years to finalize service expansion agreements. In one case an official  reported that it took 3 years to process an agreement to allow a VA  medical center to use a small area in an IHS facility for 2 days per  week, in part due to lengthy legal and contracting reviews by VA and  IHS. An official in another area reported that it took 3 years and many  layers of approval to establish an agreement between the local VA  medical center and THP provider to expand optometry services to  Native American veterans.
section_title: VA and IHS Have Provided Information and Training to Improve Cultural Competency, but Cultural Variation among Tribes and Staff Turnover Limit Its Effectiveness
paragraphs: Department of Health and Human Services, Substance Abuse and Mental Health  Services Administration, CultureCard: A Guide to Build Cultural Awareness – American  Indian and Alaska Native, SMA 08-4354 (January 2009). the military; and (3) presentations by VA to THP facility staff about  PTSD and traumatic brain injury.
The effectiveness of cultural competency training has been limited by  cultural variation across some tribes and by the challenges of high staff  turnover in some VA and IHS facilities.
Cultural variation: IHS officials explained that customs and beliefs  may vary in important ways across different tribes, and this presents a  challenge for providing training that adequately addresses these  variations, particularly in cases where VA and IHS facilities serve  Native American veterans from multiple tribes. For example, in one  site visit area, IHS officials at a facility that primarily served one tribe  reported that their native healing practices were different than those of  other nearby tribes with regard to the selection of a traditional healer  to participate in healing ceremonies. Native American veterans from  the tribe reported that if VA and IHS providers did not understand  these differences it would make it difficult for their tribal members to  obtain culturally competent health care treatment.
High staff turnover: Native American veterans with whom we spoke  during our site visits identified high staff turnover as an issue affecting  cultural competency. Native American veterans said that the use of  temporary staff and the high degree of provider turnover limit the  effectiveness of any training in cultural competency, which in turn can  diminish the quality of care provided. Without training in cultural  competency, provider staff may not be aware of important issues,  such as how to effectively communicate with Native American  veterans about their health or how to diagnose certain symptoms  unique to veterans.
section_title: Reimbursement Agreements Are in Place in Many Locations, but Site-Specific Factors and Circumstances Have Limited Establishing Such Agreements in Other Locations
paragraphs: IHS and VA collaborated at the national and local levels to establish a  VA-IHS reimbursement agreement that applies to all IHS facilities and to  encourage THPs to develop reimbursement agreements with VA. Under  such agreements, VA pays IHS and THP facilities for eligible services that  they provide to eligible Native American veterans. VA, IHS, and THP  officials said that reimbursement agreements may improve access to care  because the presence of the agreements may encourage IHS and THP  facilities to be more active in outreach and encouraging of enrollment of  Native American veterans into VA. This could provide more opportunities  for Native American veterans to obtain health care at any type of facility,  as well as obtain services they would not otherwise have access to,  including services targeted at veterans, such as PTSD counseling and  treatment, as well as specialty services unavailable at the IHS or THP  facility. The actions taken by the agencies include the development of a  national reimbursement agreement between VA and IHS facilities and the  development of individual reimbursement agreements between VA and  some THPs.
National reimbursement agreement covering IHS: VA and IHS  officials explained that together the agencies developed a national  reimbursement agreement as well as procedures and systems  through which VA payments may be made to IHS facilities. In  addition, VA and IHS agency staff worked at the local level to  complete implementation plans with each IHS facility and its area VA  medical center. Officials reported that all 81 local implementation  plans were in place as of July 2013. According to these officials,  implementation planning at the local level involved: (1) “get to know  you” sessions, in which local VA and IHS officials shared information  about what services were provided by their respective facilities;   (2) training of IHS staff about VA’s eligibility, billing, and enrollment  processes; (3) registration of the IHS facility into VA’s payment  system; and (4) setting up the IHS facility site for billing to VA. Data  provided by VA indicates that as of April 8, 2014, VA had paid a total  of $3.28 million for services provided to 2,047 Native American  veterans at IHS facilities.
Reimbursement agreements with THPs: In addition to a national  agreement, VA officials said that VA had established 53  reimbursement agreements with THPs as of May 16, 2014, and  conducted additional outreach through tribal letters and events to  educate other THPs about the option of establishing these  agreements. Data provided by VA indicate that as of April 8, 2014,  VA had paid a total of $1.99 million for services provided to 307  Native American veterans at THP facilities.
Challenges cited by officials at VA, IHS, and THP facilities included  delays in activating established reimbursement agreements and  obstacles to establishing agreements with additional THPs.
Delays in starting reimbursement under established agreements:  Not all IHS and THP facilities that are covered under reimbursement  agreements have received reimbursement. While there are currently  over 130 facilities covered under such agreements, as of April 8, 2014  only 86 had received reimbursement for services provided in fiscal  year 2014. According to agency officials, although many agreements  are in place, it may take some time before reimbursement will begin at  some IHS and THP facilities. Before reimbursement can begin,  eligible Native American veterans must be identified as such.  However, the previously mentioned challenges of a lack of data that  identifies veterans as Native Americans and high staff turnover among  IHS facilities have hindered efforts to identify these eligible individuals,  according to officials. VA officials said that it takes time to firmly  establish the procedures for providing and transmitting complete  claims information. For example, some THP facilities do not have the  ability to file electronic claims and therefore the process for submitting  claims needs to be worked out at each THP, sometimes using paper  filing. Officials also said that in some cases the time required to  establish reimbursement procedures is extended as a result of staff  turnover at THPs. In one case it took a year before the THP’s staff  consistently provided the necessary information on submitted claims  forms.
Obstacles to establishing agreements with additional THPs:  Factors such as the time it may take to establish a reimbursement  agreement as well as the perceived lack of need for agreements may  discourage some THPs from pursuing such agreements. Officials said  that while the reimbursement agreement between VA and IHS applies  to all IHS facilities, VA’s agreements with THPs need to be negotiated  individually and are based on each tribal facility’s specific  circumstances, such as whether it has the accreditation status  required by VA to provide care for veterans, and assessment of these  unique situations will require time and resources. VA and IHS  officials said that some THPs may choose not to invest the time and  resources needed to establish agreements for a variety of reasons.  For example, the THP may be located near a VA facility and not  believe it is necessary to establish such an arrangement. One THP  official we interviewed noted that it can take a long time to develop a  reimbursement agreement with VA. THP officials cited a range of  issues that need to be worked out in these agreements, such as the  reimbursement rate, requirements for provider credentialing and  privileging, and whether electronic health records would be  exchanged. VA has created a template for agreements with THPs  which addresses these issues and may expedite the process of  finalizing agreements. However, VA officials noted that THPs may  propose changes to the template language, and each agreement  requires a legal review and a contracting officer’s review and  signature. VA may have disincentives to sign such agreements as  well. For example, VA officials at one facility reported the concern that  pursuing a reimbursement agreement with area THPs could divert  funds from VA facilities if Native American veterans shifted from using  VA services to using THP services.
section_title: VA and IHS Lack a Defined Approach for Effectively Implementing and Overseeing the MOU
paragraphs: VA and IHS lack a defined approach for effectively implementing and  overseeing the MOU, and we identified three main contributing factors.  First, oversight of the MOU’s implementation is inconsistent and, in 2013,  the officials tasked with this oversight did not meet and did not  systematically evaluate the progress of MOU implementation. Second,  according to agency officials, no formal policies or guidance have been  developed that outline the procedures to implement the MOU, which limits  the agencies’ ability to hold individuals accountable for its implementation.  Third, leadership in VA and IHS have not made MOU implementation a  priority, which threatens the ability of the two agencies to move forward in  implementing the MOU. Without consistent oversight, formal guidance on  responsibilities for MOU implementation, and the prioritization of MOU  implementation, leadership in VA and IHS do not have reasonable  assurance that the objectives of the MOU related to access to care are  being addressed.
subsections: section_title: Implementation and Oversight Are Inconsistent
paragraphs: Standards for Internal Control in the Federal Government require that the  agency’s organizational structure define key areas of authority and  responsibility, and also that appropriate and clear internal reporting  relationships be established. The standards further require top-level  reviews of actual performance to track achievements and compare goals  and objectives, as well as the assessment of the quality of performance  over time to ensure that actions are promptly taken in response to  findings or recommendations. They also specify that it is important not  only to establish, but also to review, performance measures to ensure  they are working as intended. Furthermore, our prior work on interagency  collaborations found that collaborating agencies should work together to  define and agree on respective roles and responsibilities, including how  the efforts will be led. This work also found that federal agencies  working together need to create the means to monitor and evaluate  efforts to identify areas for improvement.
In implementing the MOU, VA and IHS have not complied with these  standards or good practices. For example,
While the Joint Implementation Task Force held meetings in 2011 and  2012, the full Joint Implementation Task Force has not met since  2012 according to several agency officials, and it was the  understanding of one agency official that this group was on a hiatus.  Another official with a key role on the Joint Implementation Task  Force reported being unaware of who actually led this task force.  Another official with a key role on the Joint Implementation Task  Force reported that while some of its members met in 2013 to work on  implementing the national VA/IHS reimbursement agreement, these  meetings did not focus on MOU oversight.
As of April 2014, officials responsible for leading the Joint  Implementation Task Force told us that they had not systematically  reviewed or analyzed information in the work group or Native  American Inventory quarterly reports for fiscal year 2013, although  officials in VA said they had reviewed selected reports for specific  purposes, such as learning what types of training were being provided  by VISNs. However, the leaders of the Joint Implementation Task  Force did not comprehensively track the information provided and  therefore did not provide oversight to identify priority action items for  work groups or possible obstacles to achieving the goals of the  MOU.
As of fiscal year 2013, the Joint Implementation Task Force has not  systematically identified strategies and plans for accomplishing tasks  related to the MOU moving forward or addressed challenges or  implemented best practices.
Furthermore, although work groups were tasked with reporting MOU- related activities each quarter, only 28 of the 44 work group quarterly  reports due for fiscal year 2013 (64 percent) were submitted.  Members of one of the five work groups with whom we spoke reported  that they no longer held work group meetings regularly.
Based on our assessment, these problems occurred in 2013 because VA  and IHS leaders were not holding themselves or others accountable for  their role in implementing the MOU. Without reviewing the quarterly work  group reports, and ensuring that all required reports are submitted, VA  and IHS leaders do not have reasonable assurance that the objectives of  the MOU related to access to care are being addressed. In addition, they  may be unaware of challenges and obstacles that VISNs, IHS and THP  facilities, and work groups are encountering.
section_title: Written Policies and Guidance Are Lacking
paragraphs: While VA and IHS have informal procedures to track and oversee actions  taken under the MOU, the agencies have not developed written policies  and guidelines governing implementation of the MOU. Our prior work on  interagency collaborations found that agencies that articulate  agreements—in areas such as leadership, roles and responsibilities and  accountability—in formal documents can strengthen their commitment to  working collaboratively. According to VA and IHS agency officials, the  only documentation outlining the procedures to report VA and IHS  progress in implementing the MOU is contained in a set of training slides  used in a December 2012 staff training session. Based on the information  presented in the slides, the procedures are generally consistent with  Standards for Internal Control in the Federal Government. (See figure 1  for a diagram of our interpretation of the procedures outlined in the  training slides).
The slides include an organizational chart and other information that  establish clear reporting relationships and assign key roles and  responsibilities to agency staff.
Each MOU work group is required to collect information and develop a  quarterly report detailing the types of activities it has conducted  related to MOU objectives, including the objectives aimed at taking  actions to improve access to care.
The MOU coordinators are responsible for providing assistance and  training to work groups, aggregating information from the work group  reports and other sources such as VA’s Native American Inventory  Reports, and submitting a quarterly report for review by the Joint  Implementation Task Force.
The Joint Implementation Task Force, made up of officials from VA  and IHS including leaders from certain work groups, is responsible for  oversight, including reviewing quarterly reports that are submitted by  the MOU coordinators, and identifying plans for accomplishing MOU  goals going forward. These slides stipulate that the Joint Implementation Task Force should hold regular meetings to review  progress and set priorities.
However, VA and IHS officials said that these training slides are not  binding because they have not been formalized in written policy or  guidance, including establishing clearly defined roles and responsibilities.  Without formal written policy or guidance to govern the implementation of  the MOU, VA and IHS have little basis to hold those responsible for  implementing the MOU accountable for effectively managing the  implementation process.
section_title: Prioritization of MOU Implementation Is Lacking
paragraphs: VA and IHS leaders have not made MOU implementation a priority, which  threatens the ability of the two agencies to move forward in implementing  the MOU as it relates to access to care. This is demonstrated in a number  of ways. First, according to officials, the Joint Implementation Task Force  has not created any written policy or guidance that specifically defines  roles and responsibilities for agency staff under the MOU. Moreover, key  members of the Joint Implementation Task Force attributed their lack of  tracking and oversight of the MOU activities in part to their perception that  other work-related responsibilities had a higher priority than some of their  MOU related responsibilities. The leaders of the Joint Implementation  Task Force from both agencies reported that MOU responsibilities were  not their top priority, and that resource constraints have affected their  ability to focus attention on oversight of MOU implementation. For  example, officials from ORH reported that, while it is the lead office within  VA responsible for MOU-related activities, it is also responsible for many  other initiatives. The office experienced staff turnover in 2012 and 2013,  replacing 4 of its 11 staff members, including members of the leadership  team. As a result, current leadership and some staff have only been in  their current positions since April 2013 or later and have not had time to  fully focus on MOU implementation and oversight. Similarly, an IHS  official stated that IHS has limited resources, that agency staff are  stretched in order to complete their primary responsibilities, and that  activities related to the MOU are a part of their additional  responsibilities.
VA and IHS officials reported that they have plans to examine efforts to  implement the MOU by looking at the effectiveness of the work group  structure. Specifically, VA and IHS have entered into an agreement to  have VA’s National Center for Organization Development undertake an  assessment of the views of work group members about their experience  and about whether they think the goals of the MOU are being met. The  assessment is scheduled to be completed by May 2014 and, according to  officials, will be used to identify best practices for improved efficiency and  effectiveness, or the need for adjustments to organizational structure or  processes. It is unclear at this point, however, whether this study will fully  address the implementation and oversight shortcomings we have noted  and whether it will spur greater focus on the leadership required to  effectively implement the MOU.
section_title: Native American Veterans and Their Representatives Reported Mixed Views on Whether Access to Care Has Improved
paragraphs: Although the majority of Native American veterans and their  representatives we contacted reported that they thought access to care  for Native American veterans had improved over the past 3 years, a  number of others said either that they did not believe that access to care  had improved during that time or they did not know whether it had. In  addition, there were mixed perceptions about the degree to which VA and  IHS-funded facilities had made improvements in providing care that was  culturally competent with regard to the needs of Native Americans or  veterans.
Most Native American veteran representatives that we contacted via  questionnaire perceived that there had been improvements in access to  care, such as increases in the number of Native American veterans being  enrolled in the VA health system and getting health care services.  However, others did not see that any gains had been made or did not  know. For example, Native American veteran representatives that we  contacted provided the following responses to our web-based  questionnaire when asked about whether there has been a change in the  number of Native American veterans enrolled in the VA:
Of the 102 representatives, 63 said they thought enrollment had  increased, 11 said enrollment had remained the same, 5 said that  enrollment had declined, and 23 said they did not know whether  enrollment had changed.
Of the 102 representatives, 53 reported that in the last 3 years there  had been an increase in the number of Native American veterans  accessing health care at a VA, IHS, or THP facility. However, 12 felt  that there had been no change and 36 reported that they didn’t know.  Of the 53 respondents who reported that there had been an increase  in access, 41 reported that access had improved at VA facilities,   25 reported that access had improved at IHS-run facilities, and   24 reported that access had improved at THPs.
Native American veterans and their representatives we interviewed  reported similar opinions about whether there had been improvements to  access to care. Specifically, most of the 12 interviews we conducted with  veterans or their representatives included one or more comments  indicating that access to health care had improved. Examples of  comments indicating that access had improved included the statements  “the area VA liaison had played a big part in increasing  use  and enrollment,” and “as a result of the assistance provided by TVRs to  Native  veterans, they have better access to more health care  services.” However, all of the interviews included one or more comments  specifying challenges to access, such as the lack of awareness on the  part of Native American veterans about VA benefits and what services  are available to them, lack of transportation, long waiting times, and the  lack of enough providers in certain areas such as behavioral health and  substance abuse. In addition, some of the interviews included one or  more comments by Native American veterans and their representatives  that indicated that they thought that access had not improved.
There were also mixed views about the extent to which VA and IHS  facilities had made improvements in providing care that was culturally  competent with regard to the needs of Native Americans or veterans. For  example, Native American veteran representatives who responded to our  web-based questionnaire reported the following when asked whether they  thought there had been changes in culturally competent care for Native  American veterans at different types of facilities:
Of 102 representatives, 38 said care at VA facilities had generally  improved with respect to its cultural competency, 28 said there had  been no change, 9 said it had declined, and 26 said they did not know  if there had been improvements;
Of 102 representatives, 36 said care at IHS-run facilities had generally  improved with respect to its cultural competency, 25 said there had  been no change, 9 said it had declined, and 32 said they did not  know; and for THPs, 37 said care at THPs had generally improved  with respect to its cultural competency, 25 said there had been no  change, 8 said it had declined, and 32 said they did not know.
In many of the 12 site visit interviews we conducted, Native American  veterans made one or more comments that care was not culturally  competent. For example, in one interview a Native American veteran said  that the local VA providers did not understand the cultural needs of his  tribe. In another interview, Native American veterans and their  representatives said that veterans have significant issues around PTSD  and domestic and sexual violence, but that the local IHS health facility  was not addressing these issues. At the same time, many of the 12 site  visit interviews we conducted also included one or more positive  comments about cultural competency. One noted that there had been an  increase in the provision of culturally competent care provided by VA  because VA had hired a Native American to help with outreach, and  another noted that care from their tribal clinic was culturally competent  with respect to veterans’ needs in part because the facility had a  specialist providing wound care who had experience working with  veterans.
section_title: Conclusions
paragraphs: Native American veterans have historically faced many issues in  accessing health care and to their credit, both VA and IHS have taken  actions under the 2010 memorandum of understanding to improve access  to care for Native American veterans. However, significant unresolved  challenges still remain that the agencies need to address. Moreover,  many Native American veterans and their representatives we contacted  believed that the agencies need to build upon actions already taken to  improve access for Native American veterans. Addressing access  challenges and further improving the overall access to care for Native  American veterans is hampered by ineffective oversight and the lack of  accountability and prioritization of MOU-related responsibilities among  those tasked with implementing the MOU. Written policies, procedures,  and guidelines have not been developed to lay out roles and  responsibilities, methods for collecting and disseminating information  about MOU implementation activities, oversight mechanisms, and the  process for assessing progress and developing strategies going forward.  Absent clear, binding policies and guidance, oversight and accountability  have waned and staff have not assessed progress, addressed barriers, or  set priorities for how to accomplish the MOU goals going forward. The  lack of oversight also makes it difficult for VA and IHS to know how well  MOU activities are being carried out, to identify potential best practices for  nationwide implementation, or to address existing or future challenges  and strategies. Ultimately, access to VA and IHS facilities could be  negatively affected and further progress in improving access  compromised.
section_title: Recommendation for Executive Action
paragraphs: To improve access to care for Native American veterans through MOU  implementation, we recommend that the Acting Secretary of Veterans  Affairs and the Secretary of Health and Human Services take the  following action:  Establish written policy or guidance designating specific roles and  responsibilities for agency staff to hold leadership accountable and  improve implementation and oversight of the MOU. In developing written  policies and guidelines, strong consideration should be given to the  guidance embodied in the training slides from December 2012, including  the following:
Develop an organizational chart clearly outlining the VA and IHS MOU  structure and detailing agency staff roles and responsibilities.
Require that regularly scheduled meetings be held by the Joint  Implementation Task Force or other groups charged with the  oversight of MOU implementation.
Ensure that VISNs and the MOU work groups submit reports to VA  and IHS quarterly, as well as ensure that the groups charged with the  oversight of MOU implementation complete reviews and analyses of  the information collected to assess MOU progress and address any  deficiencies.
Ensure that the Joint Implementation Task Force, or other groups  charged with oversight of MOU implementation, identifies strategies  and plans for accomplishing tasks related to the MOU to implement  best practices and address challenges.
section_title: Agency Comments
paragraphs: We provided draft copies of this report to VA and HHS for review. Both  agencies concurred with our recommendation and in their comments on  the draft described the plans for implementing the recommendation. Most  noteworthy, they reported that the agencies will develop an organizational  chart outlining VA and IHS MOU structure and agency roles and  responsibilities, hold quarterly leadership meetings to provide oversight  and guide the direction of MOU implementation efforts, and adopt and  disseminate a Standard Operating Procedure outlining data reporting and  submission requirements for work groups responsible for MOU  implementation. We have reprinted the comments from VA in appendix I  and the comments from HHS in appendix II. VA also provided technical  comments, which were incorporated in the draft as appropriate.
We are sending copies of this report to appropriate congressional  committees, the Acting Secretary of Veterans Affairs, and the Secretary  of Health and Human Services. The report is also 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  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 III.
section_title: Appendix I: Comments from the Department of Veterans Affairs
section_title: Appendix II: Comments from the Department of Health and Human Services
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Gerardine Brennan, Assistant  Director, Ashley Dixon, Carolyn Fitzgerald, Lori Fritz, Mary Giffin,   Laurie Pachter, and Jeanette Soares made key contributions to this  report.
section_title: Related GAO Products
paragraphs: The following is a list of related products.
VA and IHS: Further Action Needed to Collaborate on Providing Health  Care to Native American Veterans. GAO-13-354. Washington, D.C.:   April 26, 2013  Native American Veterans: DOL Needs a Clear Plan to Improve  Employment and Training Services on Tribal Lands. GAO-13-664.  Washington, D.C.: September 26, 2013.