VA and DOD Health Care: Department-Level Actions Needed to Assess Collaboration Performance, Address Barriers, and Identify Opportunities
Published: 2012-09-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: VA and DOD operate two of the nation's largest health care systems at estimated annual costs of about $53 billion and $49 billion, respectively, for fiscal year 2013, and have established collaboration sites to deliver care jointly with the aim of improving access, quality, and cost-effectiveness of care. In addition, collaborations could help reduce duplication and overlap between the two health care systems, potentially saving tax dollars and helping VA and DOD provide more efficient and effective services.
A committee report accompanying the Consolidated Appropriations Act, 2012, directed GAO to report on aspects of VA and DOD collaboration. This report examines the extent to which (1) VA and DOD assess effectiveness and efficiencies at collaboration sites; (2) barriers exist that affect collaboration; and (3) VA and DOD identify opportunities for collaboration. GAO conducted site visits to selected VA and DOD collaboration sites; reviewed VA and DOD documents such as sharing agreements; and interviewed VA and DOD officials.
section_title: What GAO Found
paragraphs: The Department of Veterans Affairs (VA) and Department of Defense (DOD) do not require that all collaboration sites--locations where the two departments share health care resources through hundreds of agreements and projects--develop and use performance measures to assess their effectiveness and efficiency. Officials cited several reasons for this, including not wanting to overburden sites with measures and monitoring requirements. Although VA and DOD require some limited performance information--such as the return on investment for pilot projects--without comprehensive performance measures, they lack information that could help decision makers assess collaboration sites' overall progress in meeting the departments' shared goals of improved health care access, quality, and costs; identify areas for improvement; and make informed decisions. Also, the departments cannot document the overall cost effectiveness of their collaboration efforts. In the absence of required measures for all sites, some have developed their own, but these fragmented efforts do not provide sufficient information about the overall results of collaborations.
The departments face a number of key barriers that hinder collaboration efforts. In particular, GAO identified incompatible policies and practices in four areas:
Information technology (IT) systems . Because VA and DOD collect, store, and process health information in different IT systems, providing access to information needed to best treat patients has proved problematic.
Business and administrative processes . Different billing practices, difficulties capturing patient workload information, and overlapping efforts in credentialing providers and computer security training reduce efficiency.
Access to military bases . Balancing base security needs with veterans' needs to access medical facilities on base creates some difficulties.
Medical facility construction . Misaligned construction planning processes hinder efforts to jointly plan facilities to serve both VA and DOD beneficiaries.
Although VA and DOD officials have taken some steps to address these areas, such as efforts to improve data sharing, without additional department-level actions, barriers will continue to hinder collaboration and lead to inefficiencies.
VA and DOD do not have a fully developed process for systematically identifying all opportunities for new or enhanced collaboration. Instead, the identification of those collaboration opportunities is largely left to local medical facility leadership. Although the departments have a process for jointly identifying a select number of sites with opportunities for new or expanded collaboration, that process does not address all opportunities for collaboration across both health care systems and there is no requirement that sites identified by that process move forward to implement collaboration. Without a fully developed process to systematically identify and select additional collaboration opportunities, the departments may miss opportunities to achieve their shared goals and reduce duplication of services, such as through additional sharing agreements.
section_title: What GAO Recommends
paragraphs: GAO recommends several actions, including that VA and DOD: require collaboration sites to develop performance measures related to access, quality, and costs; address barriers hindering collaboration; and develop a process to more systematically identify new or expanded collaboration opportunities. VA and DOD generally concurred with GAO's recommendations and noted steps they are taking to address them.

section_title: Letter
paragraphs: The Departments of Veterans Affairs (VA) and Defense (DOD) operate  two of the nation’s largest health care systems, together providing health  care to nearly 16 million veterans, servicemembers, military retirees, and  other beneficiaries at estimated annual costs of about $53 billion and   $49 billion, respectively, for fiscal year 2013. Although the two  departments have different missions, both provide health care services  and have been authorized to exchange health care resources since the  1982 enactment of the Veterans’ Administration and Department of  Defense Health Resources Sharing and Emergency Operations Act.  Specifically, VA and DOD were authorized by the act to enter into  contracts or sharing agreements to improve access to, and the quality  and cost-effectiveness of, health care provided by the two departments.  Subsequently, the departments have instituted a policy that allows VA  and DOD to charge one another at least 10 percent less for clinical  services than they would in locations without sharing agreements.
Since the 1980s, VA and DOD have entered into many types of  collaborations to provide health care services—including emergency,  specialty, inpatient, and outpatient care—to VA and DOD beneficiaries,  reimbursing each other for the services provided. These collaborations  vary in scope, ranging from agreements to jointly provide a single type of  service to more coordinated “joint ventures,” which encompass multiple  health care services and facilities and focus on mutual benefit, shared  risk, and joint operations in specific clinical areas. The departments also  have collaborated on the joint construction of medical facilities and have  jointly funded pilot projects related to VA and DOD collaboration activities.  The Secretaries of Veterans Affairs and Defense both have expressed  their commitment to greater collaboration between the two departments  on several issues of common interest, including better health care access  for servicemembers, veterans, and other VA and DOD beneficiaries, and  to most effectively use resources.
VA and DOD’s current and future efforts to collaborate on the delivery of  health care services have the potential to yield significant cost savings  and other benefits, such as a reduction in the duplication of health care  services. We have previously reported that reducing or eliminating  government-wide duplication could potentially save billions of tax dollars  annually and help agencies provide more efficient and effective services.  This is especially important for VA and DOD given that the departments  have experienced and continue to experience rising health care costs.  Specifically, both VA’s and DOD’s fiscal year 2013 budget requests  reflect anticipated medical care expenses that are more than double their  2001 costs. Duplication and overlap can occur for a variety of reasons,  including that agencies lack information on the effectiveness of programs  that could help decision makers prioritize resources among programs. We  have previously identified the need for improvement in the evaluation of  current and potential VA/DOD collaboration efforts, as well as challenges  VA and DOD face in their efforts to share health care resources. Efforts  leading to a reduction in duplication and overlap can help inform decision  makers as they address escalating fiscal pressures currently facing the  federal government.
A committee report accompanying the Consolidated Appropriations Act,  2012, directed GAO to report on aspects of VA and DOD collaboration.
In this report, we examine the extent to which  1.  VA and DOD assess effectiveness and efficiency for locations where  they collaborate to deliver joint health care services;   2.  Barriers exist that affect VA and DOD collaboration to deliver joint  health care services, and whether the departments have developed  strategies to address these barriers; and  3.  VA and DOD identify opportunities for collaboration to deliver joint  health care services.
To address these three objectives, we conducted site visits, attended the  2011 VA and DOD joint venture conference, reviewed documentation,  conducted interviews with VA and DOD officials, and reviewed relevant  GAO reports.
We conducted site visits to 2 of the 10 joint ventures—Honolulu,  Hawaii, and Biloxi, Mississippi—where we met with officials from VA  and DOD to discuss and observe their collaboration efforts. We also  reviewed and analyzed documents from the locations we visited, such  as sharing agreements, performance measures, and any estimates  local officials had calculated of cost savings related to their  collaboration. As part of the site visit to Biloxi, we also met with  leaders from nearby military treatment facilities that collaborate with  that VA facility. In addition, we visited Ft. Benning in Columbus,  Georgia and interviewed VA and DOD officials to learn about plans for  collaboration in that location.
We attended the annual VA and DOD joint venture conference in  October 2011, where we obtained information during detailed  presentations given by all 10 joint ventures regarding their  collaboration efforts, the problems they face, and plans for future  sharing opportunities; heard presentations by VA and DOD  department-level officials; and toured the Charleston, South Carolina,  joint venture site. This information led to the identification of key  barriers affecting VA and DOD collaboration.
We reviewed and analyzed relevant VA and DOD documentation,  including the VA/DOD Joint Strategic Plan for Fiscal Years 2011-2013  (Joint Strategic Plan) and departmental and joint VA/DOD guidance  regarding collaboration options, approaches used to identify  opportunities for collaboration, and performance measures required of  collaborating VA and DOD partners.
We interviewed VA and DOD department-level officials, including  officials from both departments’ collaboration offices, construction  planning offices, and the Interagency Program Office responsible for  joint VA/DOD information technology (IT) initiatives. We also  interviewed officials from the three military services—the Army, the  Navy, and the Air Force—who are involved with VA/DOD  collaboration efforts, as well as officials from some of VA’s 21  regional Veterans Integrated Service Networks (VISN).
We reviewed our past work, including reports on best practices for  federal agency collaboration efforts, VA and DOD’s efforts to share  medical information between the two departments, the status of VA  and DOD’s efforts to establish an integrated federal health care center  in North Chicago, Illinois, and best practices for establishing  evaluation criteria to assess federal programs.
We conducted this performance audit from November 2011 through  September 2012 in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: VA and DOD have distinct missions and health care systems to provide  services to their respective beneficiaries. VA and DOD provide some  similar services in locations where they have facilities near each other,  and have established an organizational structure to plan and carry out a  variety of joint projects. In addition, there are several options for VA and  DOD collaboration to deliver health care services jointly.
subsections: section_title: VA and DOD Health Care Systems
paragraphs: In addition to having separate missions—VA’s to serve America’s  veterans, and DOD’s to provide the military forces needed to deter war  and protect the country’s security—the departments have distinct health  care systems through which they provide a range of health care services   In addition, each has a framework that  to their respective beneficiaries.outlines its vision and goals for the care and services they deliver.
VA’s health care system includes a network of approximately 150  hospitals, 130 nursing homes, 800 community-based outpatient clinics, as  well as other facilities to provide care to veterans. VA also purchases care  from outside its network as needed to provide services for its  beneficiaries. VA estimates it will serve 6.3 million patients in the VA  health care system in fiscal year 2013 and has requested $52.7 billion for  its health care services for that year. VA’s “I CARE” framework broadly  outlines the department’s goals for delivering health care services and in  particular, cites the importance of access to, and the quality and cost of,  VA health care.
DOD’s health care system—known as the Military Health System—  serves about 9.6 million beneficiaries. According to a 2011 Congressional  Budget Office report, DOD’s health care costs are projected to reach   $59 billion by 2016 and nearly $92 billion by 2030. DOD provides care  through its system of approximately 60 military treatment facilities that  provide diagnostic, therapeutic, and inpatient care; hundreds of clinics;  and by purchasing care from a network of private-sector civilian  providers. Each of the military services, under its respective surgeon  general, is responsible for managing its own military treatment facilities.  The Military Health System’s “Quadruple Aim” outlines the department’s  vision for delivering health care services and—similar to VA’s I CARE  framework—emphasizes health care access, quality, and costs.
section_title: VA and DOD Organization for Collaboration and Joint Strategic Planning
paragraphs: VA and DOD have an organizational structure in place to plan and carry  out a variety of joint projects and collaboration efforts. (See fig. 1.)
Specifically, the Joint Executive Council—co-chaired by the Deputy  Secretary of VA and the Under Secretary of Defense for Personnel and  Readiness—is made up of senior VA and DOD officials and provides  broad strategic direction for interagency collaboration between the two  departments. The Health Executive Council, a subcouncil of the Joint  Executive Council, provides oversight for the specific cooperative efforts  of each department’s health care organizations. The Health Executive  Council has organized itself into a number of work groups to carry out its  responsibilities. For example, Health Executive Council work groups  focus on issues such as financial management, pharmacy, and IT, among  several others. In addition to this interagency structure, there are  department-level coordination offices—VA’s VA/DOD Sharing Office and  DOD’s DOD/VA Program Coordination Office. These offices coordinate  with, but do not have a direct reporting relationship to the Joint Executive  Council and the Health Executive Council.
The Joint Executive Council and the Health Executive Council also  provide oversight to the 10 joint ventures by providing some level of  direction and support for their activities. (See fig. 2 for the locations of the  current joint ventures.)
Further, the Joint Executive Council has developed the Joint Strategic  Plan, which conveys the direction and goals for collaboration efforts for  the two departments. The plan outlines the departments’ primary goals,  which include developing a health care system that delivers quality,  access, satisfaction, and value, consistently across the departments, and  establishes a national model for effective and efficient delivery of benefits  and services through collaboration. The plan also outlines specific  initiatives designed to ensure leadership, commitment, and accountability  for VA and DOD’s collaboration activities.
section_title: Options for VA and DOD Collaboration to Deliver Health Care Services
paragraphs: There are three primary options for collaboration that VA and DOD may  pursue to jointly deliver health care services: sharing agreements, joint  ventures, and Joint Incentive Fund (JIF) projects (see table 1).  Collaboration sites can pursue a combination of these sharing options.
For example, a site with sharing agreements in place can pursue joint  venture status or JIF project funding. In addition to these collaboration  options, the departments are required by law to consult with each other  regarding certain potential joint construction projects. Department-level  officials from VA and DOD identify opportunities for joint construction and  coordinate through their respective budgeting and construction planning  processes.
section_title: VA and DOD Do Not Require Participants in All Types of Collaboration to Develop Performance Measures to Assess Their Effectiveness and Efficiency
paragraphs: We have reported extensively on the importance of developing and using  performance measures for effective management and strategic planning,  as well as for measuring the achievement of projected cost savings, and  other performance goals. Furthermore, we have noted that such  performance measurement information can assist decision makers in  assessing progress and identifying areas for improvement. In addition,  the VA and DOD health care collaboration statute, as well as VA and  DOD’s own health care goals, all highlight access, quality, and costs as  important considerations in the delivery of health care. Finally, VA and  DOD department-level officials said it is important to consider costs as a  part of both departments’ responsibilities to ensure their collaboration  efforts are financially sound and improve care.
Performance measures are important to show the extent of progress  made in improving access and quality of care, in addition to cost savings  achieved, if any, from collaborations. For example, although VA and DOD  department-level officials believe that some savings occur when  collaboration sites adopt sharing agreements in which partners pay each  other less for care than they would otherwise pay community providers,  the overall savings are unclear because sites are not required to develop  performance measures to assess the extent of their savings. The  importance of performance measures regarding costs is highlighted by  our prior work on the consolidation and integration of federal facilities—in  particular, how such activities can result in unexpected costs that may  affect overall results. For example, the North Chicago Federal Health  Care Center joint venture experienced unanticipated costs associated  with its integration of VA and DOD services, such as hiring the equivalent  of 23 full-time staff to manually perform work that was originally expected  to be automated. The impact of these additional costs on that integration  overall, however, is unknown, because VA and DOD have not established  cost-related performance measures. Without performance measures in place to assess VA and DOD’s collaboration efforts, the overall value of  these efforts is unclear.
According to VA and DOD department-level officials, the departments do  not require that all collaboration sites develop and use performance  measures to assess the collaborations’ effectiveness and efficiency, in  particular to measure their progress in meeting the departments’ shared  goals of improved health care access, quality, and costs. Officials from  both departments cited several reasons why VA and DOD do not require  all collaboration sites to develop and use performance measures related  to the departments’ shared goals. In particular, VA officials told us they do  not want to overburden sites with performance measures and monitoring  requirements, which they said may discourage future collaborations. VA  officials also told us that department-level VA and DOD collaboration  offices do not have direct control over medical facilities and are not  required to provide oversight or monitoring of performance. Finally, DOD  officials said that because each collaboration is unique, performance  measures appropriate for one location might not be appropriate for  another location.
Although VA and DOD do not require all collaboration sites to develop  and use performance measures, the departments do require some limited  performance information for certain collaboration options. For example, to  receive JIF project funding, sites must estimate the return on investment  and propose performance measures related to that estimate and other  projected benefits, such as improved access or quality of care. Sites that  receive such funding must then periodically use and report on those  performance measures during and at the conclusion of the project. In  addition, beginning in fiscal year 2013, joint ventures and other selected  collaboration sites will be required to report on performance measures to  indicate areas where sites have achieved at least a 5 percent reduction in  costs or other improvements in efficiency that result from health care  collaborations. VA officials told us these measures are not meant to  represent overall savings achieved as a result of collaborating, but rather  savings from specific, self-selected areas the collaboration sites choose  to measure. Although these efforts represent initial steps toward better  understanding of the performance and progress of collaboration sites,  officials acknowledged that more work remains to be done. VA and DOD  officials told us that both departments are working to develop criteria to  determine the success of the 10 joint ventures, which they anticipate will  be based on the departments’ shared goals. As of July 2012, VA  department-level officials told us that a set of proposed criteria were still  being reviewed internally. They noted that the time frame for  implementing those criteria would still need to be determined, in part  because the departments would need to resolve data collection and  analysis issues—such as ensuring that collaboration partners had access  to reliable and timely information—before any resulting measures could  be developed and used to assess sites’ progress.
In the absence of a department-level requirement for performance  measures for all collaboration sites, some sites we reviewed have  developed their own performance measures. Although this information  may assist local medical facility leaders to understand the progress and  areas for improvement at their sites, the fragmented nature of these  efforts does not provide department-level decision makers with  information about overall performance or results of VA and DOD  collaborations. For example:
Officials from the Biloxi VA and one of their DOD collaboration  partners, Naval Hospital Pensacola, told us that their established  discounts for the inpatient services that DOD provides to VA patients  through a sharing agreement—the standard 10 percent discount from  fiscal years 2009 through 2011, changed to a larger 25 percent  discount beginning in June 2012—had resulted in a reported  cumulative savings of about $200,000 for VA since fiscal year 2009,  as of July 2012.
Honolulu joint venture officials reported that they assess efficiency by  tracking the amount of time it takes to schedule appointments for  patients who were referred to them by their collaboration partner.  Additionally, they measure quality of care using measures derived  from patient feedback information. Officials told us that by assessing  these measures they are able to identify trends and help ensure that  patients are accessing health care.
section_title: VA and DOD Face Several Significant Barriers That Hinder Collaboration, Despite Taking Some Actions to Address Those Barriers
paragraphs: VA and DOD face a number of significant barriers that hinder their  collaboration efforts. We have previously reported that federal agencies  can facilitate and enhance their collaboration efforts by establishing  compatible policies, procedures, and other ways of operating across  boundaries. Some problems VA and DOD face are inherent to the  differing missions of the two departments. However, we also identified  several important areas where VA and DOD’s lack of compatible policies  and practices at the department level and at local collaboration sites  hinders collaboration efforts. These incompatible policies and practices  fall into four areas: (1) IT systems’ ability to share health information,   (2) business and administrative processes in place at current  collaboration sites, (3) procedures for veterans to access medical facilities  on military bases, and (4) joint VA and DOD planning for construction of  medical facilities. Although VA and DOD officials at the department and  local levels have taken some steps to address issues in these areas,  significant barriers remain. Without additional department-level actions to  address incompatible policies and practices, those barriers will continue  to hinder collaboration efforts and lead to inefficiencies at the local level.
subsections: section_title: IT Systems’ Ability to Share Health Information
paragraphs: As we have reported for over a decade, VA and DOD lack IT systems that  permit the electronic exchange of comprehensive patient health   Access to  information, a significant barrier in their collaboration efforts.comprehensive health information is important to providing optimal care  to patients who receive health care services from both VA and DOD.  However, because VA and DOD collect, store, and process health  information in different IT systems, providing access to the information  needed to best treat those patients has proved problematic.
At collaboration sites, the departments’ IT barriers hinder ongoing efforts  in many ways. As we have previously reported, a health care provider  who lacks access to comprehensive health information about a patient  may be challenged to make the most informed treatment decisions,  potentially putting the patient’s health at risk. The provider also might  unknowingly order diagnostic tests that have already been performed,  leading to added health care costs. In addition, providers’ inability to use  their own facility’s IT system to easily view the health care records of their  collaboration partner’s patients can lead to costly inefficiencies. For  example, the North Chicago Federal Health Care Center joint venture  hired five full-time pharmacists specifically to conduct manual checks of  patient records to reconcile allergy information and identify possible  interactions between drugs prescribed by providers in both VA and DOD  systems. Similarly, Biloxi joint venture officials reported having to rely on  inefficient and time-consuming approaches to share information, including  manually copying or transferring medical information such as diagnostic  images between VA’s and DOD’s IT systems, or faxing information to  their collaboration partner, where it must be entered into the partner’s IT  system.
Collaboration sites have taken steps to facilitate information sharing, but  officials noted that those efforts had limitations and that IT barriers  remained. For example, Honolulu joint venture officials developed an IT  tool—called “Janus”—that allows providers to view their patients’ VA and  DOD health care records on a single screen. Officials said this tool has  helped providers treating shared patients in a number of ways, providing  clinical benefits and allowing providers to work more efficiently. Officials  said, for example, that Janus gives providers a more efficient way to view  and share diagnostic images taken by collaboration partners and to  compare clinical information in both partners’ systems, such as patients’  medication allergies and laboratory results. However, they noted that it is  a “read only” tool that doesn’t allow providers to enter data into the other  department’s IT system; as a result, there are some inefficiencies when  providers must take time to separately perform data entry steps outside of  their Janus IT tool. At the Biloxi joint venture, staff in some clinical areas  use side-by-side dual computers: one to access VA health care records  and another to access DOD health care records. (See fig. 3.) Biloxi  officials reported that although this approach helps, it is time-consuming  and costly, and does not allow staff to share information as efficiently as  they would like; for example, there are costs to set up the dual computers  and it takes providers extra time to access both IT systems to review  information and share information with their collaboration partners. Biloxi  officials also are working with VA and DOD at the department level to test  a way of electronically sharing diagnostic images between facilities.
At the department level, VA and DOD have worked for many years to  improve the ability of their IT systems to share medical information, and  have spent millions of dollars on those efforts, but those efforts have not  yet led to a comprehensive solution. As we have reported, VA and DOD  have increased their ability to electronically share information through a  patchwork of initiatives. In April 2009, the President announced that the  departments would define and build the Virtual Lifetime Electronic Record  to streamline the transition of electronic medical, benefits, and  administrative information between the departments. Over the past few  years, the departments also began working to develop IT capabilities to  facilitate information sharing at the North Chicago Federal Health Care  Center joint venture that were intended to be “exportable” for use at other  VA and DOD collaboration sites. However, those efforts have been  delayed, in some cases indefinitely, resulting in costly and inefficient  workarounds.
Most recently, the departments began work on a new common integrated  electronic health record (iEHR) that both VA and DOD would use for their  beneficiaries. In March 2011, the Secretaries of VA and Defense  committed the two departments to developing this new health record and  in May 2012 announced their goal of implementing it across the  departments by 2017. Officials from the joint DOD/VA Interagency  Program Office (IPO), which is leading the iEHR effort, told us they have substantial financial resources for the iEHR effort, reporting funding of  nearly $550 million across both VA and DOD for iEHR in fiscal year 2012  alone. They also said they have made some key decisions about the  project. For example, IPO officials plan to begin work at the Honolulu joint  venture in September 2012 on IT tools that would be part of the larger  iEHR effort, and test initial elements of iEHR at two pilot sites in 2014.
However, the implementation time frame for the new iEHR effort is  uncertain. IPO officials told us in April 2012 that they planned to  implement elements of iEHR in a phased approach over time, but that full  implementation may not occur for at least 4 to 6 years, and that this  estimated time frame was both optimistic and uncertain. They said the  IPO office was not yet fully staffed, nor did they have final plans for how  iEHR would be developed and implemented given that many decisions  had yet to be made. For example, they had not yet determined what  clinical applications iEHR would include, the time frame for implementing  different elements of iEHR across all VA and DOD sites, or the order in  which they would implement iEHR at collaboration sites. IPO officials  noted that once they complete their work at the iEHR pilot sites they will  have a better sense of how the project would proceed. They added that  they might select a limited number of other sites to use elements of iEHR  as part of their early work on the project; they noted that although they  had not yet developed criteria for selecting those additional sites, the joint  venture sites would be among those considered.
Overall, given the uncertainty about when and how iEHR will be  implemented, it is not clear when collaboration sites could expect to see  benefits from this new effort. Although local officials have expressed  interest in obtaining IT tools from the departments in the short term to  help address their IT barriers, IPO officials said their focus is on  developing iEHR rather than implementing separate IT tools at individual  facilities. In their view, separate interim efforts to improve the  interoperability of facilities’ existing health IT systems would take time and  resources away from the larger effort to replace those existing systems  with iEHR, and it might only be beneficial to invest in local IT efforts that  inform the IPO’s iEHR work. Until collaboration sites receive IT support  from the departments, they will continue to face IT barriers. In addition,  sites will continue to rely—and expend resources on—their own solutions  to address those barriers. Without information from the departments  regarding the plans for iEHR—specifically, the time frame for when joint  ventures and other collaboration sites might begin to have iEHR solutions  implemented—local officials will not know when they could begin to see  changes due to this new effort and be able to plan accordingly.
section_title: Collaboration Sites’ Business and Administrative Processes
paragraphs: VA and DOD collaboration sites face a number of barriers with business  and administrative processes that hinder collaboration and are important  to their daily operations: reimbursement, capturing information on care  provided to patients, credentialing of providers, and computer security  training.
Reimbursement for services provided to patients. Aspects of the  reimbursement process—such as assigning diagnostic and procedure  codes to episodes of care (coding), and authorizing and paying for  services—can pose problems, particularly when VA and DOD practices  differ. These problems can result in inefficient workarounds at the local  level, and difficulties such as backlogs of unpaid bills. Honolulu joint  venture officials shared several examples of reimbursement-related  difficulties including that the collaboration partners do not use the same  coding and billing standards, which can lead to discrepancies that can be  difficult to quickly resolve. Staff at DOD’s Tripler Army Medical Center  code and bill care provided to veterans based on Military Health System standards, while VA staff reviewing those bills apply VA’s standards,which can lead to difficulties reconciling the two approaches. Honolulu  officials said that differences in how VA and DOD treat same-day  surgeries, for example—VA considers them outpatient services while  DOD considers them inpatient services—lead to the need to manually  handle those bills, which takes time.
Honolulu VA and DOD officials agreed that reimbursement difficulties  have had a substantial impact on their collaboration efforts, including on  their finances. A January 2012 Army review of billing issues at this  collaboration site found that there was more than $20 million in bills from  Tripler unpaid by VA for fiscal years 2009 through 2011, which included  bills that had not yet been processed or had been denied by VA. A July  2011 VA coding audit of bills submitted by Tripler Army Medical Center  stated that, as compared to VA’s coding standards, DOD’s coding was  accurate for about 80 percent of the codes used in the sample of bills  reviewed. The audit made recommendations to reduce the number of bills  needing manual review and expedite VA’s payment of bills submitted by  Tripler. However, Honolulu VA and DOD officials did not always agree  with each other on the specific extent or the causes of their  reimbursement difficulties.
Biloxi officials also shared examples of reimbursement issues. They  noted that differences in VA and DOD coding practices temporarily led to  delays in VA paying bills for care provided at Keesler Air Force Base,  because some VA and Air Force staff involved with billing and paying for  care were not initially familiar with the other collaboration partner’s  reimbursement practices. In addition, they sometimes have needed to  negotiate solutions when VA and DOD’s reimbursement practices differ.  For example, they had to agree on a reimbursement rate that would apply  when Keesler billed VA for certain ambulatory procedures in a way that  followed DOD guidance but was new to VA staff.
Honolulu and Biloxi officials have taken some steps to address problems  with reimbursement, though difficulties remain. Honolulu officials said  implementing an IT tool called “eDR”their business processes and that bills are now submitted in a faster  automated way rather than through the time-consuming manual method   has improved several aspects of  previously used. Biloxi officials created the Joint Venture Business Office  to help standardize and streamline their collaboration site’s business  processes. Officials reported that this office facilitates communication  about issues such as coding and billing and helps resolve any difficulties  that arise.
At the department level, VA and DOD officials said VA and DOD have  taken some steps to address reimbursement issues, but that sites will still  need to find ways to bridge VA and DOD’s differences. VA and DOD  department-level officials have worked with Honolulu officials to address  their difficulties. For example, a group of VA, Army, and other DOD  officials began meeting in September 2011 to address coding issues at  the Honolulu joint venture; as of June 2012 their work was still ongoing. In addition, the departments supported the eDR effort at the Honolulu  joint venture by providing more than $3 million through JIF project  funding. Also, VA officials told us that VA has been working since 2009 to  implement the Intra-Governmental Payment and Collection System—a  federal government effort to provide a standardized interagency fund  transfer mechanism for federal agencies—which should help streamline  how VA receives and pays bills from DOD, although it would not  specifically address coding. Officials noted, however, that work on this  system has been halted or delayed several times, due in part to a lack of  funding; as of June 2012 VA officials were discussing when and how to  proceed but no final decisions had been made. Honolulu VA officials said  that this system would help improve their reimbursement process.
DOD officials told us that while some coding difficulties occur at collaboration sites other  than at the Honolulu joint venture, the extent of the problem in Honolulu is unique and is in  part due to the large volume of care that the Army provides to VA at that location. evaluate and to justify the resources needed for their collaboration efforts.  These officials also noted that workload information can affect facilities’  future funding. For example, leaders may be reluctant to support new JIF  project funding for additional providers if a collaboration site’s current  providers seem underutilized due to the lack of workload information.
Among the collaboration sites’ difficulties collecting workload information,  Biloxi VA officials said that, until recently, they were unable to capture  workload information when Biloxi VA surgeons treated veterans at one of  their DOD collaboration partners—Naval Hospital Pensacola—because  that information was not captured through the billing process or in VA’s IT  systems. DOD has faced similar problems when its providers care for  patients at the Biloxi VA facility. In addition, Honolulu VA officials said  reimbursement difficulties have led to delays in getting and paying bills  from Tripler, which has hindered their ability to capture workload  information through the billing process in a timely way.
Biloxi and Honolulu officials have taken some steps to better collect  workload information. Biloxi officials reported a recent approach in which  Biloxi VA staff already located at Naval Hospital Pensacola collect  information about the care VA surgeons provide there; that information is  later entered into VA’s IT system. Officials said this new solution seems to  work well, but takes time and resources, and is not as efficient as if their  IT systems allowed an easier way to collect this information. In addition,  some DOD providers who treat patients at the Biloxi VA facility now  separately enter workload information into DOD’s IT system. Biloxi DOD  officials said this solution is a work in progress, but it would be preferable  if the IT systems allowed them to capture workload information, as some  clinical staff have said they don’t have time for this extra data entry step.  Honolulu officials said that while they still have difficulties capturing  workload information as quickly as they would like, that their eDR IT tool  improved their ability to capture workload information in a more timely  way by automating aspects of the reimbursement process.
At the department level, VA officials told us that the Intra-Governmental  Payment and Collection System effort related to bill payment would help  VA capture information when its providers deliver care at DOD facilities,  so that those providers and the VA facilities can get credit for the  workload. Honolulu VA officials said this system would improve their  ability to collect workload information because that information would  automatically be captured when they paid bills from DOD. As of June  2012, there had been no DOD-wide efforts to deal with workload capture  issues.
Dual credentialing of providers. Providers who deliver care in both VA  and DOD facilities as part of collaboration efforts must be “credentialed”  by both facilities. Credentialing is a process in which health care providers  are systematically screened and evaluated for their qualifications and  other credentials, including their licensure, education, training, and  current competence. Biloxi and Honolulu joint venture officials said that  the credentialing process is time-intensive and that dual credentialing  creates some duplication of effort as staff members repeat many  credentialing steps already completed by their collaboration partner.  Honolulu VA officials added that dual credentialing also can create delays  between the time new providers join their facility and when they can begin  clinical work at their collaboration partner’s facility, because the extra  credentialing steps must first be completed. They said that it also  complicates staffing. For example, if a dually credentialed VA social  worker who works at Tripler Army Medical Center is on vacation or is ill,  VA cannot send a non-dually credentialed social worker to take that  person’s place.
At the department level, to address concerns about dual credentialing, a  Health Executive Council review resulted in a December 2010  memorandum of understanding between VA and DOD that was intended  to facilitate credentialing and reduce the time and costs associated with  dual credentialing. The memorandum established guidelines for how  credentialing information collected and verified by one department can be  shared with the other department. Under these guidelines, VA and DOD  facilities can share a range of information about providers as part of the  credentialing process, such as details about providers’ education and  training. However, VA and DOD facilities must still independently verify  information that can expire or go out of date, such as providers’ licensure  and board certification status. Biloxi officials told us that the ability to  use credentialing information collected by their collaboration partner has  helped facilitate the credentialing process, but noted that there is still a  fair amount of overlapping credentialing work to conduct. VA and DOD  department-level officials told us, in their view, the departments have  done all they can to streamline dual credentialing.
Overlapping computer security training. According to VA and DOD,  staff involved with collaboration efforts have to complete both VA and  DOD computer security training to access both departments’ IT systems,  which leads to some overlap in effort and loss of productivity because of  the time it takes staff to complete the dual training. The Health Executive  Council began work in June 2009 on a demonstration project examining  how to reduce the overlapping mandatory training taken by VA and DOD  staff, and selected computer security training as one of four high priority  focus areas.
In August 2011, VA formally accepted three of the four DOD courses  reviewed as part of this demonstration, and as a result, will grant  reciprocity when DOD staff complete those courses and will not require  DOD staff to take VA’s corresponding training courses. Although VA  developed a strategy for implementing this decision, as of May 2012 the  department had not made any progress in implementing the strategy,  according to VA officials. They cited a number of delays and said that VA  training of management staff would begin work on this effort once a  separate VA computer security initiative had been fully implemented;  however, they did not have an expected time frame for when  implementation would occur. In contrast to VA, DOD decided not to grant  reciprocity to VA staff for their VA computer security courses because,  according to DOD, officials decided that VA’s courses were not similar  enough to DOD’s to warrant reciprocity.
section_title: Accessing Medical Facilities on Military Bases
paragraphs: According to VA and DOD officials, the procedures DOD uses to maintain  security at military base entrances can hinder access to medical facilities  located on bases for veterans and those accompanying them. Base  access procedures are critical to protecting DOD personnel and assets;  they are established locally by military leaders at each base on the basis  of factors such as that base’s specific security needs and guidance from  the department and the military services. The need to ensure base  security may add some complexity and time for veterans and their escorts  accessing care on the base, as DOD personnel perform security checks  as part of their base access procedures. Such procedures may include  determining whether veterans and their escorts have sufficient  identification, and proof of vehicle insurance and registration; as well as  inspecting the vehicles transporting the veterans. (See fig. 4.) In some  cases, base personnel may require veterans to provide documentation of  their health care appointment or may conduct background screening in  which the veteran is vetted against government databases, such as the  National Crime Information Center. Access procedures can change over  time because of changes in local military leadership, guidance, and other  factors such as security threat levels.
Officials told us these base access procedures can take time and in some  cases—such as during specific episodes of heightened security—may  prevent veterans from accessing care in a timely manner. Veterans who  are late to health care appointments due to access difficulties might be  unable to receive care and have to return for rescheduled appointments.  Such missed appointments can lead to lost revenue for the military  treatment facility, which will not receive reimbursement as expected, as  well as inefficiencies, when staff time allotted for seeing patients goes  unused. In addition, VA department-level officials told us that base access  issues could dissuade some local VA officials from partnering with DOD  medical facilities. Base access procedures also can lead local officials to  spend time and resources developing and implementing approaches to  try to facilitate veterans’ access to care.
Collaboration sites have taken some actions to mitigate the impact of  base access procedures on veterans and their escorts and facilitate  access to care.
In some locations, base access issues have factored into officials’  efforts to build facilities on base with unique security arrangements.  For example, VA’s outpatient clinic is on the perimeter of the Navy  base that houses Naval Hospital Pensacola, and is separated from  the rest of the base by a security fence, which Biloxi VA and Navy  officials said facilitates easy public access for both veterans and Navy  personnel. Officials implemented a similar approach at Eglin Air Force  Base, also in Florida, where a VA clinic on Air Force property is  separated from the rest of the base by a gate that requires fingerprint  verification to allow entry. Officials noted that while these approaches  improve veterans’ access to these VA outpatient facilities located on  DOD property, difficulties can still arise when veterans seek  emergency, inpatient, or other care from the military facilities located  on base.
Biloxi officials started a shuttle service to transport veterans from the  VA medical center to Keesler Air Force Base to facilitate access for  veterans and their escorts, including those who may not otherwise  meet certain requirements for base entry; for example, veterans and  their escorts avoid the need to meet vehicle registration and  inspection requirements. This shuttle, however, requires added staff  and resources. According to officials, as a separate effort, staff call to  remind patients of the documentation needed to access the base;  however, patients still sometimes fail to bring the required  documentation, which can result in extra time needed to access the  base and sometimes lead to missed health care appointments.
In Honolulu, Army officials decided to accept VA’s Veteran  Identification Card as a valid form of identification for veterans going  to Tripler Army Medical Center for health care services, which officials  said improved access for veterans although not their escorts. Despite  this action, it can still take a lengthy amount of time for veterans and  their escorts to access the base because there is only one entry point  for all individuals entering the base, including VA and DOD staff, and  as a result long lines at the gate are common. (See fig. 5.) Honolulu  VA officials told us that base access considerations have factored into  their efforts to work with DOD to expand health care services through  a new medical facility elsewhere in the community rather than by  adding to the existing facilities on the base.
Although collaboration sites have been pursuing base access solutions at  the local level—and the departments have been aware of base access  issues for some time—the departments recently initiated their first joint  effort to identify potential strategies for facilitating veterans’ access to  care on military bases while also meeting base security needs, according  to VA and DOD officials. Specifically, the Joint Chiefs of Staff initiated a  new workgroup composed of VA and DOD officials to assess the military  services’ current base security guidance and determine potential actions  that could facilitate veterans’ access. As of July 2012, this workgroup had  met once to discuss the issues and to begin its review of relevant  guidance. One potential action the workgroup is considering is addressing  how military bases treat the Veteran Identification Card as part of base  access procedures. Currently, the military services have different  guidance regarding the use of the card by veterans for base access  purposes. VA department-level officials said that broader, more uniform  acceptance of the card across the military services would be a useful step  in facilitating access for veterans, but noted that it would not be a  comprehensive solution, because it would not apply to people  accompanying veterans to their appointments.
VA and DOD could face some difficulties identifying base access  solutions that meet the security needs of military leadership, given the  varied and changing security needs at the local level. However, without a  sustained joint effort at the department level to explore ways to remove  barriers to care across collaboration sites, veterans’ ability to access  medical care will vary considerably. In addition, local officials will continue  to spend time and resources developing and implementing workarounds  to try to appropriately balance DOD’s need to maintain base security with  veterans’ need to access care.
In addition, given the base access difficulties that can arise, it is important  for sites to consider base access issues when they are considering new  or expanded collaboration. Both DOD and VA department-level officials  noted that base access is a critical consideration for collaboration efforts,  and VA officials added that they raise the issue with local officials who are  planning new collaborations. However, officials acknowledged that  current guidance from both departments about VA and DOD collaboration  efforts—such as memoranda of agreement and understanding between  the departments, and key department-specific handbooks and  instructions—does not explicitly address base access or encourage local  officials to prospectively identify potential base access issues and ways to  address them.
section_title: Joint VA and DOD Planning for Construction of Medical Facilities
paragraphs: VA and DOD department-level officials reported that several barriers  hinder their efforts to jointly plan construction of medical facilities to serve  both departments’ beneficiaries, and sometimes lead to missed  opportunities to collaborate. For example, VA’s and DOD’s separate  processes for reviewing proposed projects—including joint projects—are  not well aligned. The processes occur on different timelines and use  different criteria to rate and rank proposed projects, and in the past there  has been no formal mechanism for the departments to systematically  share information to identify opportunities for joint projects, according to  officials. As a result, a potential joint project may not move forward if it is  not deemed high priority by both departments,departments cannot secure approval and funding for it in the same time  frame. Further, local officials may do a substantial amount of planning for  a project before contacting the other department about a potential  collaboration, and by then it may be too late to collaborate as efficiently  as possible. Officials also said that legal considerations can sometimes  affect their joint construction efforts.
Efforts to collaborate at Ft. Benning in Georgia illustrate some of the  difficulties VA and DOD have experienced in jointly planning for  construction of new medical facilities. Although VA and DOD officials saw  benefits—including the opportunity to potentially save costs and improve  patient care—to building a VA clinic that would either be part of the new  Army hospital currently under construction at Ft. Benning or on Army  property near the new hospital, the departments’ misaligned construction  planning and funding processes were barriers to this effort, according to  VA and DOD officials. Despite discussions within the departments about  a potential joint effort at Ft. Benning, officials could not align the funding  and approval processes for such an effort. Officials have also considered  another option—colocating a new VA clinic with a new Army clinic  elsewhere in the community, but have not been able to move forward with  that option either. Local VA and DOD officials noted that the inability to  build a VA clinic at the new Army hospital site or to colocate the clinics in  the community likely reduced some opportunities to avoid costs and  improve access to care. For example, VA officials said having a VA clinic  at the new hospital site likely would have allowed VA and DOD to share  the same laboratory and radiology services and could have improved  access by having VA and DOD resources on one campus. VA  department-level officials noted that the inability to move forward with joint  construction at this location does not preclude local officials from  collaborating through sharing agreements.explored establishing its new clinic in another location in the community,  not colocated with the Army clinic, but as of May 2012 no final decisions  had been made about where VA will locate its new clinic.
Most recently, VA has  As an example of how legal considerations can affect joint construction  efforts, officials from VA in Biloxi and one of its DOD collaboration  partners, Naval Hospital Pensacola, wanted to build a joint VA/DOD clinic  on Navy property in Panama City, Florida, but due to legal considerations  ultimately decided to instead build two separate clinics in close proximity.  Specifically, officials said they changed their plans after learning that  combining VA and Navy funds for a single joint clinic would have  exceeded VA’s statutory limit for minor construction projects because the  total funding amount—not just VA’s contribution—would count toward the  statutory limit. Officials said if they had reduced the project’s scope to fall within VA’s minor construction limit, it would not have met their needs  for clinical care, so they instead opted to build two separate clinics.  Officials were not certain of the cost impact of providing services in two  clinics rather than one, but believed doing so would be less efficient and  potentially more costly. For example, they said a single clinic would have  allowed for some logistical streamlining and avoided the need to duplicate  building services like electrical utilities. The departments could have  pursued this project as a major construction project rather than as a minor  construction project, but would have needed to obtain congressional  authorization to do so, since major construction projects generally must  be specifically authorized by Congress. VA and DOD department-level  officials added that potential major construction projects must compete  internally for approval; as a result, the departments would not necessarily  have approved this joint project to proceed as a proposed major  construction project.
VA and DOD have taken several steps that have the potential to help  overcome some of the departments’ differences and improve joint  planning for medical facility construction. For example, VA and DOD  officials participate in each other’s construction planning processes, so  they can provide insight on each department’s projects under  consideration and on other potential collaboration projects; officials said  that doing so has helped their collaboration efforts. The departments have  also worked together on legislative proposals that, in their view, could  enhance their ability to collaborate on joint efforts. For example, VA, in its  fiscal year 2013 congressional budget submission, stated that it would  propose legislative changes that would allow VA to transfer funds to—and  receive funds from—another federal agency to use for the planning,  design, or construction of a shared or joint medical facility, or to lease  space for such a facility; in June 2012, VA department-level officials told  us they were working on VA’s legislative proposal. DOD is exploring  similar legislative changes. In addition, the departments are improving  their information sharing to better inform their planning processes. As an  initial step, VA and DOD department-level officials identified several types  of data to be shared between the departments to help identify  collaboration opportunities early in the construction planning process. As  a result, as part of the most recent round of VA’s planning process, local  VA officials had access to information such as DOD population and  workload information to help them identify opportunities for joint  construction and leasing. Department-level DOD officials said they would  share VA population and workload data with the military services during  the next round of DOD’s planning process as well. Officials from both  departments said they plan to build on these initial efforts by refining their  data sharing processes. For example, officials are exploring sharing  additional types of data to inform their departments’ construction planning  processes and have identified the need to institute a more formalized  process for sharing data with local officials.
section_title: VA and DOD Do Not Have a Fully Developed Process for Systematically Identifying New and Enhanced Collaboration Opportunities
paragraphs: VA and DOD do not have a fully developed process for systematically  identifying opportunities for new or enhanced collaboration that could  facilitate the departments’ shared goals of improving access, quality, and  costs. Instead, the identification of new or enhanced collaboration  opportunities is largely left to local medical facility leadership. Although  the departments do have a process for jointly identifying a select number  of sites where there are opportunities for new or expanded collaboration,  that process does not address all options for collaboration across both  health care systems, nor is there a requirement that the sites identified by  that process move forward with collaboration. Until VA and DOD fully  develop a joint process to systematically identify and pursue potential  collaboration opportunities, the departments may miss opportunities to  improve patients’ access to and quality of care, and to reduce costs, such  as by addressing overlap and duplication of services that may exist  between the two health care systems.   we reported on ways  In our previous work on interagency collaboration,for agencies to facilitate and enhance their collaboration efforts, including  ways to reduce the costly government duplication and overlap that can  cost taxpayers billions of dollars each year. Our prior work has found that  strategic direction is required as the basis for collaboration. As such,  defining roles and responsibilities and mechanisms for coordination can  help agencies clarify who will lead or participate in which activities,  organize their joint activities and individual efforts, and facilitate decision  making. In addition, agencies can facilitate and enhance their  collaboration efforts by establishing compatible ways of working together  across agency boundaries.
However, VA and DOD do not have a fully developed process and a  sufficient strategic direction to work across agency boundaries to fully  identify collaboration opportunities. Specifically, the departments have not  fully developed and formalized a systematic process to review all  possibilities for new and expanded collaboration, but instead largely leave  the identification of new or enhanced collaboration opportunities to  leaders at local VA and DOD medical facilities. For example, the  decisions to pursue sharing agreements, JIF project funding, and joint  venture status are at the discretion of local leadership. Neither  departmental or joint VA and DOD guidance describe a systematic  department-level process for the identification of all potential collaboration  opportunities that may exist between the departments. DOD’s instruction  that governs health care collaboration with VA states that the leaders of  DOD’s military treatment facilities are to monitor emerging opportunities  for collaboration and to conduct financial analyses and negotiate sharing  agreements with local VA medical facilities, among other things. Similarly, VA’s handbook that defines procedures for health care  collaboration with DOD medical facilities states that leadership of VA  medical centers may decide to pursue collaboration options with DOD  such as sharing agreements, JIF project funding, and joint venture  status.said these decisions are largely left to local leaders because they do not  have authority over local facilities; rather they can only offer guidance.  Further, officials said local-level officials have more direct knowledge of  their locations, and as such, are better positioned to assess their unique  circumstances and determine what types of collaboration make the most  sense.
DOD, DOD and Department of Veterans Affairs Health Care Resource Sharing  Program, DOD Instruction 6010.23 (Jan. 23, 2012). departments acknowledged that collaboration is dependent on local  leaders’ personalities and willingness to collaborate; some leaders may  be greatly interested in exploring collaboration opportunities, while others  may not. Moreover, given the regular changes in military treatment facility  leadership, local leaders’ interest and commitment to collaborating can  change over time. One additional difficulty with decisions made outside of  a broader systematic process is that local medical facility leadership may  not have readily available access to information necessary to examine  what health care services could benefit from collaboration. For example,  local leaders may not know when providing certain health care services  through collaboration efforts rather than by purchasing care from non-VA  or non-DOD providers would be likely to result in significant cost savings.  Without comprehensive information on such purchased care, officials may  be hindered in their efforts to identify areas or services that could be  purchased from or provided to a partner facility at a lower negotiated rate,  thus reducing costs to the federal government and possibly providing  additional nonfinancial benefits. Some local officials we spoke with said  they encountered difficulties obtaining purchased care information from  their collaboration partner, and in one case encountered some resistance  internally regarding sharing such information with their partner.
In an effort to facilitate more department-level direction and systemize the  identification of collaboration opportunities, the departments implemented  a process to identify a select number of sites where there are  opportunities for new or enhanced collaboration, and designate them as  Joint Market Opportunities (JMO) sites. However this process has  limitations, because it does not identify all opportunities; is not formalized  in guidance; and is not enforceable, as local officials still have discretion  about which opportunities to pursue. Since 2009, a Health Executive  Council work group—composed of VA and DOD department-level officials  and representatives from the military services—has designated a few new   using criteria that have changed over time, but have  JMO sites annually,included the proximity of VA and DOD facilities to each other, the size of  local VA and DOD beneficiary populations, current working relationships  of local facility leadership, current and possible collaboration initiatives,  and current or planned construction or renovation. This work group visits  JMO sites to meet with local officials, explore collaboration options, and  make recommendations about new or enhanced sharing agreements. VA  and DOD officials define JMO sites as areas that have opportunities for  sharing resources and risk that should be explored. Currently, the  departments have identified 15 JMO sites. Several JMO sites have  resulted in new or enhanced sharing agreements as an example of  improved collaboration, according to VA and DOD officials. For example,  the Charleston, South Carolina, area was designated as a JMO, and in  subsequent years after designation, medical facility partners within that  JMO jointly constructed a new facility and obtained joint venture status.
However, the JMO process is limited as it does not involve a systematic  approach to reviewing and identifying all new or enhanced collaboration  opportunities that exist. Given that only a few JMOs are identified each  year, the departments may be missing opportunities to encourage  collaboration at other locations. Further, officials from both departments  stated there is no requirement that sites designated as JMOs pursue  greater collaboration. The work group does not have the authority to  require—or provide oversight of—implementation of their  recommendations regarding collaboration; rather, it serves in an advisory  and support function only. For example, Columbus, Georgia, was  previously considered a JMO site because of potential joint construction  between VA and the Army at Ft. Benning. An official from VA stated that  the work group performed a site visit to examine options for collaboration  and provide support and advice to local medical facility leadership, but  VA’s and DOD’s construction planning processes did not align and, as we  noted earlier, proved to be barriers to joint construction at this location.  VA officials stated the work group has not performed follow-up work to  review ongoing collaboration at this location.
section_title: Conclusions
paragraphs: Although they share a clear recognition of the potential benefit that exists  when the departments collaborate to jointly provide health care services,  VA and DOD may be missing additional opportunities to meet their  shared goals of improving the access to, and the quality and costs of,  health care, such as by reducing duplication and overlap of services. In  particular, the departments have not taken sufficient actions to: develop  and use performance measures to assess the effectiveness and  efficiency of collaboration, overcome key barriers to collaboration, and  identify new or enhanced collaboration opportunities. Specifically, the lack  of comprehensive department-wide performance measures related to  access, quality, and costs related to collaboration efforts may limit key  decision makers’ ability to adequately assess the effectiveness of those  or other future health care collaborations. Similarly, while collaboration  sites need some flexibility to implement local solutions that best meet  their needs, given that they have different characteristics and can  encounter different problems, department-level efforts to address key  barriers—such as those we identified with IT systems, business and  administrative processes, base access, and joint planning for construction  of medical facilities—could facilitate collaboration, as well as help reduce  time and resources spent by local officials developing and implementing  their own solutions. For example, additional departmental guidance about  base access could help ensure that local officials consider these issues  early in their discussions about new or expanded collaboration. Similarly,  without comprehensive department-wide solutions or assistance,  collaboration sites will continue to face significant IT challenges and  spend resources on local solutions. Finally, VA and DOD lack a fully  developed process for systematically identifying opportunities for new and  enhanced collaboration; rather they largely leave such identification to  local medical facility leadership. Without more systematic, department- level approaches to collaboration in all of these areas, opportunities to  meet their shared goals for collaboration may be out of the departments’  reach.
section_title: Recommendations for Executive Action
paragraphs: To help assess progress, identify areas for improvement, and make  informed decisions about health care collaborations, we recommend that  the Secretaries of Veterans Affairs and Defense require collaboration  sites to develop and implement a process for using performance  measures to gauge their progress in achieving goals related to access,  quality of care, and costs.
To facilitate the departments’ current collaboration efforts, we recommend  that VA and DOD systematically identify areas where department-level  actions could help address significant barriers that hinder collaboration.  Specifically, we recommend that the Secretaries of Veterans Affairs and  Defense take the following three actions: expedite and communicate a plan with time frames for when iEHR  solutions will be made available to joint ventures and other  collaboration sites;  take steps to resolve problems with collaboration sites’ incompatible  business and administrative processes, including reimbursement for  services, collection of workload information, dual credentialing, and  computer security training; and  clarify, as part of the newly initiated joint efforts to address base  access, departmental guidance regarding collaboration to include a  discussion of base access issues that local officials should consider  when discussing and planning collaboration efforts; this could include  a discussion of successful approaches that current collaboration sites  have adopted to facilitate base access for veterans and their escorts.
To fully identify potential opportunities to improve access to and quality of  care—and reduce costs as well as duplication and overlap between the  VA and DOD health care systems—the departments should further  develop a systematic process for identifying and furthering collaboration  opportunities, such as through sharing agreements and joint ventures.  This process should review the portfolios of the departments’ health care  facilities; ensure information necessary to identify collaboration  opportunities is available; identify both new and expanded opportunities  for collaboration; and assign responsibility to ensure identified  opportunities are explored and implemented if appropriate.
section_title: Agency Comments and Our Evaluation
paragraphs: DOD and VA each provided comments on a draft of this report. In their  comments, both departments generally concurred with each of the  recommendations to the Secretaries of Defense and Veterans Affairs.  (DOD’s comments are reprinted in app. I; VA’s comments are reprinted in  app. II.) In addition, both DOD and VA provided technical comments,  which we have incorporated as appropriate. The departments’ specific  responses to each of our recommendations are as follows:
To develop and implement a process for using performance measures  to gauge collaboration sites’ progress in achieving goals related to  access, quality of care, and costs, DOD and VA stated that their 2011- 2013 Joint Strategic Plan established a cost efficiency measure for  joint venture sites and noted that the Health Executive Council plans  to expand this cost efficiency measure and develop additional  measures for other collaboration sites. VA stated that a Health  Executive Council work group would develop a plan to address this  issue within 6 months of the publication of this report.
To expedite and communicate a plan with time frames for when iEHR  solutions will be made available to joint ventures and other  collaboration sites, DOD and VA stated that the IPO Advisory Board  has approved an incremental plan for development of iEHR  capabilities that results in achieving capabilities by the end of fiscal  year 2017 and that the IPO will work with a Joint Executive Council  work group to ensure stakeholders are informed of this incremental  schedule.
To take steps to resolve problems with collaboration sites'  incompatible business and administrative processes, DOD and VA  stated that the Health Executive Council will work to address issues  related to reimbursement, workload capture, and computer security  training. In addition, both departments indicated they will continue to  work with The Joint Commission to address issues related to dual  credentialing of health care providers.
To clarify departmental guidance regarding collaboration to include a  discussion of base access issues that local officials should consider  when discussing and planning collaboration efforts, DOD and VA  stated that they will disseminate within their respective departments  the outcomes of the joint effort to address base access. Specifically,  DOD stated it would disseminate those outcomes to all the  organizations within the Military Health System, and VA stated it  would disseminate those outcomes to all VA medical facilities.
To further develop a systematic process for identifying and furthering  collaboration opportunities, DOD and VA stated that they would  continue to work together to hone their joint market selection criteria  process. Both departments generally concurred with this  recommendation, but stressed the importance of the role of local  leaders in the development of collaboration. Specifically, they  emphasized that involvement of local officials is critical since they  have the best sense of their specific health care markets, which GAO  also recognizes as an important aspect of identifying and furthering  collaboration.
We are sending copies of this report to the Secretary of Veterans Affairs,  Secretary of Defense, and appropriate congressional committees. In  addition, the report is available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  us at (202) 512-7114 or draperd@gao.gov or (202) 512-3604 or  farrellb@gao.gov. Contact points for our Offices of Congressional  Relations and Public Affairs may be found on the last page of this report.  GAO staff who made major contributions to this report are listed in  appendix III.
section_title: Appendix I: Comments from the Department of Defense
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Staff Acknowledgments
paragraphs: In addition to the contacts named above, Lori Atkinson, Assistant  Director; Marcia A. Mann, Assistant Director; Robin S. Burke;   Jill K. Center; Suzanne M. Perkins; and Leigh Ann E. Sennette made   key contributions to this report. Lisa A. Motley and Michael Willems  provided legal support, and Jennie F. Apter assisted in report  development.