VA and IHS: Further Action Needed to Collaborate on Providing Health Care to Native American Veterans
Released: 2013-04-26T00:00:00


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. To enhance health care access and the quality of care provided to Native American veterans, in 2010, these two agencies renewed and revised an MOU designed to improve their coordination and resource sharing related to serving these veterans. GAO was asked to examine how the agencies have implemented the MOU.

This report examines: (1) the extent to which the agencies have established mechanisms through which the MOU can be implemented and monitored; and (2) key challenges the agencies face in implementing the MOU and the progress made in overcoming them. To conduct this work, GAO interviewed VA and IHS officials and reviewed agency documents and reports. GAO also obtained perspectives of tribal communities through attendance at two tribal conferences; interviews with tribal leaders and other tribal members, including veterans; and interviews with other stakeholders, such as health policy experts and consultants.

section_title: What GAO Found
paragraphs: The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) have developed mechanisms to implement and monitor their memorandum of understanding (MOU); however, the performance metrics developed to assess its implementation do not adequately measure progress made toward its goals. VA and IHS have defined common goals for implementing the MOU and developed strategies to achieve them. They have also created two mechanisms to implement the MOU--12 workgroups with members from both agencies to address the goals of the MOU, and a Joint Implementation Task Force, comprised of VA and IHS officials, to oversee the MOU's implementation. These steps are consistent with practices that GAO has found enhance and sustain agency collaboration. The agencies have also developed three metrics aimed at measuring progress toward the MOU's goals. However, two of the three metrics are inadequate because their connection to any specific MOU goal is not clear and, while they include quantitative measures that tally the number of programs and activities increased or enhanced as a result of the MOU, they lack qualitative measures that would allow the agencies to assess the degree to which the desired results are achieved. The weaknesses in these metrics could limit the ability of VA and IHS managers to gauge progress and make decisions about whether to expand or modify their programs and activities.

VA and IHS face unique challenges associated with consulting with a large number of diverse, sovereign tribes to implement the MOU, and lack fully effective processes to overcome these complexities. VA and IHS officials told us the large number (566 federally recognized tribes) and differing customs and policy-making structures present logistical challenges in widespread implementation of the MOU within tribal communities. They also told us that tribal sovereignty--tribes' inherent right to govern and protect the health, safety, and welfare of tribal members--adds further complexity because tribes may choose whether or not to participate in MOU-related activities. Consistent with internal controls, VA and IHS have processes in place to consult with tribes on MOU-related activities through written correspondence and in-person meetings. However, according to tribal stakeholders GAO spoke with, these processes are often ineffective and have not always met the needs of the tribes, and the agencies have acknowledged that effective consultation has been challenging. For example, one tribal community expressed concern that agency correspondence is not always timely because it is sent to tribal leaders who are sometimes not the tribal members designated to take action on health care matters. Similarly, some tribal stakeholders told GAO that the agencies have not been responsive to tribal input and that sometimes they simply inform tribes of steps they have taken without consulting them. VA and IHS have taken steps to improve consultation with tribes. For example, VA has established an Office of Tribal Government Relations, through which it is developing relationships with tribal leaders and other tribal stakeholders. Additionally, in Alaska, VA has been consulting with a tribal health organization for insight on reaching tribes. However, given the concerns raised by the tribal stakeholders GAO spoke with, further efforts may be needed to enhance tribal consultation to implement and achieve the goals of the MOU.

section_title: What GAO Recommends
paragraphs: GAO recommends that the agencies take steps to improve the performance metrics used to assess MOU implementation and to develop better processes to consult with tribes. VA and the Department of Health and Human Services agreed with these recommendations.

section_title: Letter
paragraphs: Native Americans (American Indians and Alaska Natives) have  historically served in the military at a higher rate than any other ethnic  group, according to the Department of Defense. Once separated from the  military, some Native American veterans are eligible to receive health  care services from both the Department of Veterans Affairs (VA) and the  Indian Health Service (IHS), an agency within the Department of Health  and Human Services.

To improve the health status of Native American veterans through  coordination, collaboration, and sharing of resources among VA, IHS, and  tribes, in 2010, VA and IHS expanded upon a 2003 memorandum of  understanding (MOU). This 2010 MOU outlined mutual goals for the  agencies’ collaboration and coordination of resources and care in  providing health care services to Native American veterans. For example,  it included provisions for joint contracts and purchasing agreements,  sharing staff, ensuring providers in VA and IHS could access the  electronic health records of shared patients, and the development of  payment and reimbursement policies and mechanisms to support care  delivered to Native American veterans eligible for care in both systems.

In a May 2012 congressional hearing, both VA and IHS reported that they  have taken steps to collaborate to improve access to and quality of health  care services for Native American veterans. However, questions have  been raised by members of Congress about the extent of collaboration  between the two agencies. For example, a 2012 Senate report noted that  stronger partnerships among VA, IHS, and tribally operated health  facilities are essential to ensuring Native American veterans have access  to health care services. We were asked to examine how the agencies  have implemented the MOU. In this report, we address the (1) extent to  which VA and IHS have established mechanisms through which the MOU  can be effectively implemented and monitored; and (2) key challenges  that VA and IHS face in implementing the MOU, and the progress they  have made in overcoming them.

To address both of these objectives, we reviewed the MOU and  documentation related to the MOU’s implementation, including periodic  updates and descriptions of sharing agreements. We also reviewed the  signed reimbursement agreement between VA and IHS as well as signed  reimbursement agreements between VA and tribes. We interviewed VA  and IHS officials, including VA’s Director of the Office of Rural Health and  Office of Tribal Government Relations, the IHS Chief Medical Officer, and  leaders of 8 of 12 VA/IHS workgroups tasked with addressing and  implementing the MOU to learn about the steps that have been taken to  implement and monitor the MOU and any related challenges. We  selected these eight workgroups because they were involved in  addressing issues regarding agency coordination and sharing resources.

To assess the MOU’s implementation and related challenges, we took  several actions to obtain the views of tribal communities. We attended a  VA tribal consultation on MOU implementation at the National Indian  Health Board Consumer Conference in Denver, Colorado, in September  2012, and attended the National Congress of American Indians (NCAI)  Annual Conference in Sacramento, California, in October 2012. At the  NCAI conference, we conducted listening sessions for tribal members to  solicit their views on MOU implementation. We also interviewed various  other tribal health representatives outside of the listening sessions and  the conferences. In all, we interviewed 34 tribal members and other  representatives (collectively referred to in this report as tribal  stakeholders), including tribal leaders, tribal veterans, tribal health  directors and administrators, and tribal health policy experts and  consultants. The tribes represented in our interviews were geographically  varied, including representation from 9 IHS Areas and 10 Veterans  Integrated Service Networks and included representation from tribes that  varied in size from approximately 500 members to 310,000 members. We  cannot generalize findings from these interviews as representative of all  tribal communities; however, we believe that patterns or issues identified  in these interviews may illustrate issues that other tribes face as well.

To evaluate the extent to which VA and IHS have established  mechanisms through which the MOU can be effectively implemented and  monitored, we assessed this evidence against relevant criteria from our  past work on interagency collaboration, practices from leading results- oriented public-sector organizations, and agency strategic planning. To  evaluate key challenges that VA and IHS face in implementing the MOU,  and the progress they have made in overcoming them, we assessed this  evidence against internal controls.

We conducted this performance audit from July 2012 to April 2013 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Native American Veteran Demographics
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, which we refer to as tribal sovereignty.  Specifically, federally recognized tribes have government-to-government  relationships with the United States, and are eligible for certain funding  and services provided by the United States. In addition, some Native  American veterans are members of the more than 400 Indian groups that  are not recognized by the federal government (which we refer to in this  report as non–federally recognized tribes). Many—but not all—Native  American veterans are dually eligible for health care services in VA and  IHS. For example, a veteran who is a member of a non–federally  recognized tribe may be eligible for VA health care services, but would  not be eligible for IHS health care services.

section_title: VA and IHS Structure and Benefits
paragraphs: VA is charged with providing health care services to the nation’s veterans,  and estimates that it will serve 6.3 million patients in fiscal year 2013.  VA’s fiscal year 2012 budget for medical care was approximately   $54 billion. The department provides health care services at VA-operated   Veterans who  facilities and through agreements with non-VA providers.served in the active military, naval or air service and who were discharged  or released under conditions other than dishonorable are generally  eligible for VA health care.

IHS is charged with providing health care to the approximately 2.1 million  eligible Native Americans. IHS’s fiscal year 2012 budget for medical care  was approximately $3.9 billion. Similarly to VA, IHS provides health care  services at IHS-operated facilities through direct care and pays for  services from external providers through contract health services. In  addition to IHS-operated facilities, some federally recognized tribes  choose to operate their own health care facilities, which receive funding  from IHS. Like their IHS-operated counterparts, tribally operated  facilities provide direct care services and pay for contract health services.  IHS also provides funding through grants and contracts to nonprofit urban  Native American organizations through the Urban Indian Health program  in order to provide health care services to Native Americans living in  urban areas.

section_title: VA and IHS Collaboration through Memorandums 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, the agencies developed a more detailed MOU to further these  efforts. The 2010 MOU contains provisions related to several areas of  collaboration, including actions related to the following:  Joint contracts and purchasing agreements: Development of  standard, preapproved language for inclusion of one agency into  contracts and purchasing agreements developed by the other agency;  and processes to share information about sharing opportunities in  early planning stages.

Sharing staff: Establishment of joint credentialing and privileging,  sharing specialty services, and arranging for temporary assignment of  IHS Public Health Service commissioned officers to VA.

Electronic Health Record (EHR) access: Establishment of standard  mechanisms for VA providers to access records in IHS and tribally  operated facilities, and vice versa, for patients receiving care in both  systems.

Reimbursement: Development of payment and reimbursement  policies and mechanisms to support care delivered to dually eligible  Native American veterans.

section_title: VA and IHS Tribal Consultation Policies
paragraphs: Executive Order 13175, issued on November 6, 2000, required federal  agencies to establish regular and meaningful consultation and  collaboration with Indian tribe officials in the development of federal  policies that have tribal implications. IHS issued a tribal consultation  policy in 2006 to formalize the requirement to seek consultation and  participation by Indian tribes in policy development and program activities.  According to the policy, IHS will consult with Indian tribes to the extent  practicable and permitted by law before any action is taken that will  significantly affect Indian tribes. In November 2009, a Presidential  Memorandum directed federal agencies to develop plans, after  consultation with Indian tribes and tribal officials, for implementing the  policies and directives of Executive Order 13175. VA’s plan included  development of a tribal consultation policy, which the agency released in  February 2011. VA’s tribal consultation policy asserts that VA will  establish meaningful consultation to develop, improve, or maintain  partnerships with tribal communities. The policy states that consultation  should be conducted before actions are taken but acknowledges there  may not always be “sufficient time or resources to fully consult” on an  issue.

section_title: Best Practices and Internal Control Standards for Interagency Collaboration and Performance Monitoring
paragraphs: In past work we have reported on key practices to enhance and sustain  interagency collaboration including agreeing on roles and responsibilities; establishing compatible policies, procedures, and other means to  operate across agency boundaries; and developing mechanisms to monitor, evaluate, and report on results.

Additionally, our past work has identified a range of mechanisms that the  federal government uses to lead and implement interagency  collaboration. We found that regardless of the mechanisms used, there  are key actions the government can take, including (1) having clear goals;  (2) ensuring relevant participants are included in collaboration; and   (3) specifying the resources—human, information, technology, physical,  and financial—needed to initiate or sustain the collaboration. We have  also found in past work on leading public-sector organizations and  agency strategic planning that it is important to (1) define clear missions  and desired outcomes; (2) use performance measures that are tangible,  measurable, and clearly related to goals to gauge progress; and (3) use  performance information as a basis for decision making. Finally, internal  control standards emphasize the importance of effective external  communications that occur with groups that can have a serious effect on  programs, projects, operations, and other activities, including budgeting  and financing.

section_title: VA and IHS Have Developed Mechanisms to Implement and Monitor the MOU, but Metrics to Monitor Performance Do Not Adequately Measure Progress toward MOU Goals
paragraphs: VA and IHS have documented common goals in their MOU, created   12 workgroups that are tasked with developing strategies to address the  goals of the MOU, and created a Joint Implementation Task Force to  coordinate tasks, develop implementation policy, and develop  performance metrics and timelines—actions that are consistent with those  we have found enhance and sustain agency collaboration. However, most  of the performance metrics developed by VA and IHS to monitor the  implementation of the MOU need to be more clearly related to the goals  of the MOU in order to allow the agencies to gauge progress toward MOU  goals.
subsections: section_title: VA and IHS Have Defined Common Goals and Created Mechanisms to Implement the MOU
paragraphs: Consistent with our past work on practices that can enhance and sustain  collaboration, VA and IHS have defined common goals for implementing  the MOU and developed specific strategies the agencies plan to take to  achieve them. Table 1 summarizes the five goals in the 2010 MOU and  selected strategies for implementing them.

VA and IHS have created two mechanisms to implement the MOU— workgroups and a Joint Implementation Task Force. We have reported  that MOUs are most effective when they are regularly updated and  monitored, actions that can be achieved by workgroups and task forces.

VA and IHS created 12 workgroups tasked with responsibility for  implementing and developing strategies to address the goals of the MOU,  such as interoperability of health information technology; developing  payment and reimbursement agreements; and sharing of care processes,  programs, and services. Each workgroup includes members from VA and IHS, a step that can foster mutual trust across diverse agency  cultures and facilitate frequent communication across agencies to  enhance shared understanding of collaboration goals, according to our  previous work on interagency collaboration. According to VA and IHS  officials, most of the workgroup members volunteered to serve on the  workgroups and were self-selected, and VA officials told us that they have  consulted with tribes on how to increase tribal participation in the  workgroups. The agencies also told us that some workgroup members  were asked to participate because of their subject-matter expertise.

Goals established by each workgroup appear to be aligned with MOU  goals. Specifically, all eight of the workgroups we interviewed described  goals that were consistent with the MOU goals. workgroup we interviewed and provides a crosswalk between workgroup  goals and the corresponding MOU goal or strategy.

We did not interview 4 workgroups because they did not directly relate to our objectives:  (1) Services and Benefits; (2) New Technologies; (3) Cultural Competency and  Awareness; and (4) Emergency and Disaster Preparedness.
subsections: section_title: Joint Implementation Task Force
paragraphs: VA and IHS created the Joint Implementation Task Force to oversee the  overall implementation of the MOU. This task force comprises officials  from both agencies including from the Office of the Secretary of Veterans  Affairs, the IHS Chief Medical Officer, and the director of VA’s Office of  Tribal Government Relations, and is scheduled to meet quarterly. It  develops implementation policy and procedures for policy-related issues  identified by the workgroups; creates performance metrics and timelines,  evaluates progress; and compiles an annual report on progress in MOU  implementation. Creating a mechanism, such as a task force, intended  not only to address issues arising from potential incompatibility of  standards and policies across agencies but also to monitor, evaluate, and  report on MOU results, can help to facilitate collaboration, according to  our previous work on interagency collaboration.

section_title: VA and IHS Performance Metrics Do Not Adequately Measure Progress on the MOU Goals
paragraphs: The process developed by the Joint Implementation Task Force to  monitor the implementation of the MOU includes obtaining data on three  performance metrics; however, two of the three metrics do not allow the  agencies to measure progress toward the MOU’s goals. Our previous  work has found that successful performance metrics should be tangible  and measureable, clearly aligned with specific goals, and demonstrate  the degree to which desired results are achieved. Although all three of  the performance metrics are tangible and measurable, only one is also  clearly aligned with a specific goal and defined in a manner that would  allow the agencies to adequately measure the degree to which desired  results are achieved. The other two metrics are inadequate because their  connection to a specific goal is not clear and they lack qualitative  measures that would allow the agencies to measure the degree to which  desired results are achieved. For example, one MOU goal is to increase  access to and improve quality of health care services, but none of the  metrics mention any targets specifically linked to increased access or  improved quality of care. Another goal is to establish effective  partnerships and sharing agreements among the agencies and the tribes  in support of Native American veterans. Although one of the metrics  appears to be related to this goal, in that it is focused on measuring the  number of outreach activities that are a result of partnerships, it lacks  measures to determine how well the outreach activities are meeting the  goal of establishing effective partnerships or other potential goals to  which the outreach may contribute, such as facilitating communication  among VA, IHS, veterans, and tribally operated facilities. The metrics  would therefore not enable VA and IHS to determine how well these  specific goals are being achieved. Table 3 describes the performance  metrics and performance measures and our evaluation of them.

Using these metrics, the agencies have issued MOU progress reports,  but the metrics included in the reports generally are not clearly tied  specifically to the goals of the MOU, nor do they allow the agencies to  determine how well MOU goals have been achieved. Leading public- sector organizations have found that metrics that are clearly linked to  goals and allow determination of how well goals are achieved are key  steps to becoming more results-oriented. For example:

According to the agencies’ fiscal year 2011-2012 metrics report,Metric 1 (programs increased or enhanced as a result of the MOU),  more than 15 programs were enhanced or increased as the result of  the MOU, and 440 events and activities occurred that increased or  enhanced the programs. The report then provides examples of  programs that have been enhanced, such as a care coordination  program in which a registered nurse “works with Indian Health, Tribal  Programs, and other agencies and hospitals through direct meetings  at various facilities to ensure communication and improved care.”  However, the report does not always describe information that would  allow the agencies to determine how well each activity contributes to  meeting MOU goals. For instance, in the description of an enhanced  care coordination program noted above, the report does not indicate  how the agencies determined that communication has improved  among participants. Absent this information, it is not clear how the  agencies could draw conclusions about whether improved  communication has actually been facilitated and therefore how well  the activity contributed to meeting the MOU goal of promoting patient- centered collaboration and facilitating communication.

According to the metrics report, for Metric 2 (outreach activities  increased or enhanced as a result of MOU partnerships), eight types  of activities were increased or enhanced. However, the report lists  only seven types of outreach and does not include enough information  to determine how well the outreach contributes to meeting MOU  goals. For example, one outreach activity cited in the report,  “Outreach to promote implementation of new technologies,” includes  the activity “VA Office of Telehealth Services (OTS) Coordinator  participated in Web-ex sessions with IHS on use of technology to  improve patient care.” Although not stated in the report, this activity  appears to help implement the MOU strategy of enhancing access  through the development and implementation of new models of care  using new technologies, including telehealth, related to the MOU  goals of promoting patient-centered care and increasing access to  care. However, while outreach activities are measurable and tangible,  and might help to achieve goals of the MOU, the report does not state  how the agencies will determine whether the sessions actually were  effective in improving patient care or increasing access, information  that is necessary to allow the agencies to tell how well the activity  helps achieve the MOU goals.

For each metric, the agencies report whether the activities “met the  purpose of the MOU,” “met the intent of the MOU,” and whether the  “level of VA-IHS-Tribal participation” was poor, fair, good, or excellent.  While determining whether the agencies’ activities meet the purpose  and intent of the MOU is a critical step, and obtaining tribal  participation is consistent with MOU goals, the report does not  describe how these determinations were made. Agency officials told  us that these determinations were made subjectively by each  workgroup while keeping in mind the goals and strategies in the MOU.

The weaknesses we found in these performance metrics could limit the  ability of VA and IHS managers to gauge progress and make decisions  about whether to expand or modify programs or activities, because the  agencies will not have information on how well programs are supporting  MOU goals. VA and IHS officials told us that they developed these  performance metrics because the initial performance metrics, drafted by  the workgroups themselves and other VA and IHS staff, varied in quality.  The three metrics and measures were intended to provide some simple,  measurable ways for workgroups to report on their progress. However,  they also acknowledged that there were weaknesses in the measures  and told us that refining these performance metrics is a priority. According  to the officials, they plan to revise workgroup metrics by April 2013 and on  a continuous basis going forward. In doing so, they plan to consult  subject-matter experts and existing VA and IHS performance metrics, for  example, prevention of hospital admissions in home-based primary care  programs.

section_title: VA and IHS Lack Effective Processes to Overcome the Challenges of Consulting with a Large Number of Diverse, Sovereign Tribes
paragraphs: Mainly because of the large number of diverse tribal communities and  tribal sovereignty, VA and IHS face unique challenges associated with  coordinating and communicating to implement the MOU. VA and IHS  have processes in place for consulting with tribes, but these measures fall  short in several respects and do not ensure such consultation is effective.
subsections: section_title: VA and IHS Face Challenges Implementing the MOU Related to the Large Number of Diverse, Sovereign Tribes
paragraphs: VA and IHS officials told us the large number (566) of federally  recognized tribes and differing customs and policy-making structures  present logistical challenges in widespread implementation of the MOU  within tribal communities. For instance, according to some VA officials,  in some tribes as a matter of protocol, an agency must be invited on tribal  lands or be sponsored by a council member in order to address a tribal  council. Such a policy could add administrative processes that might  delay implementation and require greater sensitivity from agency officials,  adding to the challenge of consulting with tribes. As another example, the  title or position of the tribal person designated to make decisions  regarding health care may differ from tribe to tribe, complicating the  decision-making process among VA, IHS, and tribes. VA officials told us  in some tribes, for example, a tribal leader may have several roles, only  one of which is making decisions on health care, whereas in other tribes  there may be a tribal health director whom the tribal leader has  designated to manage health care in the tribal community. Potentially,  these differences can affect the speed and degree at which collective  decisions can be made.

In addition, VA and IHS officials noted that tribal sovereignty further adds  to the logistical complexity of the efforts of the agencies to implement the  MOU. Tribal sovereignty includes the inherent right to govern and protect  the health, safety, and welfare of tribal members. Indian tribes have a  legal and political government-to-government relationship with the federal  government, meaning federal agencies interact with tribes as  governments, not as special interest groups or individuals. VA and IHS  officials told us that because of tribal sovereignty, tribally operated  facilities may choose whether or not to participate in a particular  opportunity for collaboration related to the MOU, which makes it  challenging to achieve some of the goals of the MOU. VA and IHS can  inform tribes of an opportunity but cannot require them to participate. For  example:  In order to meet the MOU goal to establish standard mechanisms for  access to electronic health record (EHR) information for shared  patients, VA and IHS have coordinated to adapt their information  technology systems to allow them both to participate in the eHealth  Exchange, a national effort led by the Department of Health and  Human Services for sharing EHR information. However, EHR  workgroup members told us that some tribally operated facilities have  opted to use an off-the-shelf product in place of the IHS system, which  the workgroup members do not have the resources to support.

In another instance, as a part of their efforts to meet the MOU goal to  establish effective partnerships and sharing agreements, VA and IHS  are working to implement VA’s Consolidated Mail Outpatient  Pharmacy (CMOP) throughout IHS. Workgroup members assigned to  these activities said they plan to implement the program in all IHS- operated facilities by spring 2013 but cannot require tribally operated  facilities to participate. Some smaller tribal communities with more  limited postal access are not interested in using the CMOP program,  according to the workgroup members.

section_title: VA and IHS Processes in Place to Overcome the Complexities Associated with Consulting with Tribes Do Not Always Ensure Effective Consultation
paragraphs: VA and IHS communicate MOU-related information with the tribes  through written correspondence, in-person meetings, and other steps, as  is consistent with internal controls calling for effective external  communications with groups that can have a serious effect on programs  and other activities; however, according to tribal stakeholders we  interviewed, these methods for consultation have not always met the  needs of the tribal communities, and the agencies have acknowledged  that effective consultation has been challenging.

VA and IHS send written correspondence (known as “Dear Tribal Leader”  letters) regarding the MOU to tribal communities. However, the agencies  have acknowledged that because of the large and diverse nature of the  tribes, they have struggled to reach the tribal member designated to make  health care decisions with information about the MOU. Both VA officials  and members of tribal communities told us that, because tribal leaders  are not always the tribal person designated to make decisions regarding  health care, the “Dear Tribal Leader” letters may not always make their  way to tribal members designated to take action on health care matters.  VA officials told us that their formal consultation is conducted with tribal  leaders. However, these officials also noted that, in addition to the letters  sent to tribal leaders, they have a network of contacts within each tribe  that includes, among others, tribal health directors, and this network  receives concurrent notice of communication with tribal leaders via  conference calls, listservs, and newsletters. IHS officials said sometimes,  in addition to the tribal leader, they may also send letters to, or otherwise  communicate directly with, tribal health program directors if they know of  them. However, they also noted they do not maintain a specific record— such as a listserv—of tribal health program directors. Without reaching  the tribal members responsible for decision-making on healthcare  matters, VA and IHS may not always be effectively communicating with  tribes about the status of the MOU and its related activities nor be  obtaining tribal feedback that is critical with respect to implementation of  the MOU.

Likewise, seven tribal stakeholders we spoke with noted similar concerns  regarding the “Dear Tribal Leader” letters as VA and IHS. For example,  one tribal stakeholder said letters should go to a specific person, such as  a tribal health director, to ensure that the information is seen by the right  people in a timely manner. It may take the tribes time to pass along letters  sent only to tribal leaders to the tribal health director or other appropriate  people, by which point any deadlines included in the correspondence  could be missed. Once the information has reached the tribal leader,  tribes bear the responsibility to ensure it is passed on to the appropriate  audience in a timely manner.

Another specific concern tribal stakeholders that we spoke with  expressed relating to written correspondence was that the agencies  sometimes use the letters to simply inform them of steps the agencies  have taken without consulting the tribes, as called for by the agencies’  tribal consultation policies. For example, some tribal stakeholders said VA  and IHS did not include them in the original development of the 2010  MOU, even though the goals and activities in the MOU could directly  affect them. According to 10 of the tribal stakeholders we spoke with,  tribes should have been included in developing the MOU, which  addresses proposed plans, policies, and programmatic actions that may  affect tribes. For example, the MOU seeks to improve delivery of health  care by developing and implementing new models of care using new  technologies, including telehealth services such as telepsychiatry.  Instead, the agencies solicited tribal comments after the agencies had  signed the MOU. According to two tribal stakeholders, the agencies were  not responsive to the comments provided on the MOU. One stakeholder  said their comments were not acknowledged upon receipt nor did IHS  ever follow up on the issues raised by their comments. The stakeholder  suggested IHS designate a point person to track feedback and ensure  follow-up. VA and IHS officials told us that they did not hold tribal  consultation meetings before the signing of the MOU because they  viewed the MOU as an agency-to-agency agreement rather than as an  agreement between the agencies and the various tribes.

VA and IHS officials said they hold quarterly meetings with tribal  communities and also attend events, such as conferences held by Native  American interest organizations. Three tribal stakeholders told us that  when the agencies have held consultation meetings, the meetings are not  interactive enough—stating that agency officials speak for the majority of  the time—and that VA does not provide enough information prior to these  meetings. These tribal stakeholders said providing information ahead of  time could allow tribes to better prepare for meetings, discuss issues as a  tribe beforehand, and determine which tribal members should attend. If  tribal officials with the authority and desire to work with VA and IHS do not  receive needed information on opportunities because of an ineffective  consultation process, local facility leadership may not have readily  available access to information necessary to examine which collaborative  opportunities are present, and thus VA and IHS may be hindered in their  efforts to coordinate health care for Native American veterans.

VA and IHS are undertaking other efforts designed to enhance  consultation with tribes. These include the following steps:  In January 2011, VA established the Office of Tribal Government  Relations (OTGR) to serve as the point of contact for tribes. According  to VA officials, this office conducted four consultation meetings in  2012 and employed five field staff to help manage communication  with tribal communities and to work with IHS on local MOU  implementation efforts.

In February 2011, VA released the agency’s tribal consultation policy.  VA officials said they are developing a report that will explain the  process for evaluating comments from tribes and making decisions  based on them. The officials expect the report to be released to the  public in the spring of 2013.

The agencies have made more local efforts to communicate with  tribes, which have led to some success. For example, agency officials  and tribal stakeholders noted that the workgroup assigned to  implement MOU activities in Alaska used successful methods for  working with tribes. The Alaska workgroup told us they cultivated a  relationship with an Alaskan tribal health organization in order to get  advice on the appropriate customs for consulting with individual tribes  there. In addition, the workgroup said they scheduled consultation  meetings in conjunction with other meetings, which would limit the  amount of travel tribal community members would need to undertake.  VA employees also took cultural awareness training, and VA officials  visited Alaska to demonstrate the agency’s dedication to providing  care to Native American veterans, which, according to the workgroup,  led to buy-in from tribal communities. VA and Alaskan tribes have  signed 26 reimbursement agreements.

Some tribal stakeholders that we spoke with have acknowledged the  steps taken by the agencies thus far as positive but in some cases  expressed concerns regarding tribal consultation. In the case of the tribes  working with the Alaska workgroup, one stakeholder praised VA’s efforts  to work with tribal health organizations to communicate with tribes. In  another example, two tribal stakeholders said they approved of OTGR’s  establishment as an office dedicated to Native American veterans’ issues.  However, four tribal stakeholders expressed concerns that, despite the  creation of OTGR, VA still has not always been effective in its efforts to  consult with tribes or be responsive to tribal input provided during  consultation. For example, one stakeholder questioned whether  consultation was done with every tribe and described VA’s consultation  process as sporadic. This stakeholder’s concern implies that VA’s  outreach efforts may not be systematically reaching all tribal communities.  However, VA officials told us that, in addition to issuing notices in the  Federal Register and Dear Tribal Leader letters, they have a systematic  process of hosting training summits for tribes and scheduling regular  conference calls and presentations to tribal leadership. In another  instance, one tribal community member said OTGR lacks—and thus  cannot disperse to tribes—the technical knowledge necessary for tribes to  partner with VA on activities such as negotiating reimbursement  agreements. VA officials noted that OTGR staff may not always be  technical experts on a given topic but said they are able to identify those  experts and play a key role in linking tribes with them.

section_title: Conclusions
paragraphs: Coordination between VA and IHS is essential to ensuring that high- quality health care is provided to dually eligible Native American veterans.  While the 2010 MOU includes common goals that should facilitate agency  coordination, and the agencies have created workgroups tasked to  implement the MOU, we found that a critical mechanism for monitoring  the implementation of the MOU, the agreement’s performance metrics,  has weaknesses. Specifically, the inadequacies we found in performance  metrics could limit the agencies’ ability to measure progress towards  MOU goals and ultimately make decisions about programs or activities.

Overcoming the challenges related to working with a large number of  diverse, sovereign tribes is also essential to successfully achieving the  goals of the MOU. Although steps have been taken to consult with tribes  regarding the MOU and related activities, consultation has not always  been effective in assuring that the people designated to make health care  decisions in each tribe are reached and tribes are included in planning  and implementation efforts. Ineffective consultation with tribal  communities could delay or limit potential VA, IHS, and tribal community  partnerships to achieve the goals of the MOU and could hinder agency  efforts to gain support for MOU activities and address the health care  needs of Native American veterans.

section_title: Recommendations for Executive Action
paragraphs: To ensure the health care needs of Native American veterans are  addressed most efficiently and effectively, we recommend that the  Secretary of Veterans Affairs and Secretary of Health and Human  Services take the following two actions:

As the agencies move forward with revising the MOU’s performance  metrics and measures, ensure that the revised metrics and measures  allow decision makers to gauge whether achievement of the metrics  and measures supports attainment of MOU goals.

Develop processes to better ensure that consultation with tribes is  effective, including the following:

A process to identify the appropriate tribal members with whom to  communicate MOU-related information, which should include  methods for keeping such identification up-to-date.

A process to clearly outline and communicate to tribal  communities the agencies’ response to tribal input, including any  changes in policies and programs or other effects that result from  incorporating tribal input.

A process to establish timelines for releasing information to tribal  communities to ensure they have enough time to review and  provide input or, in the case of meetings, determine the  appropriate tribal member to attend the event.

section_title: Agency Comments
paragraphs: We provided draft copies of this report to VA and the Department of  Health and Human Services for review. Both agencies concurred with our  recommendations. In addition, VA provided us with comments on the  draft report, which we have reprinted in appendix I, as well as general and  technical comments, which were incorporated in the draft as appropriate.

We are sending copies of this report to appropriate congressional  committees; the Secretary of Veterans Affairs; the Secretary of Health  and Human Services; and other interested parties. In addition, the report  is available at no charge on the GAO Web site at http://www.gao.gov.

If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs are on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix II.

section_title: Appendix I: Comments from the Department of Veterans Affairs

section_title: Appendix II: 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; Jennie Apter; Lori Fritz; Hannah Marston Minter; and Lisa Motley  made key contributions to this report.


Question-summary annotations: questions: question: What steps have VA and IHS taken to address the goals of the MOU?
answer: VA and IHS have defined common goals for implementing the MOU and developed strategies to achieve them. They have also created two mechanisms to implement the MOU--12 workgroups with members from both agencies to address the goals of the MOU, and a Joint Implementation Task Force, comprised of VA and IHS officials, to oversee the MOU's implementation.
child_questions: question: What are the shortcomings of the VA and IHS mechanisms to implement their MOU?
answer: The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) have developed mechanisms to implement and monitor their memorandum of understanding (MOU); however, the performance metrics developed to assess its implementation do not adequately measure progress made toward its goals. These steps are consistent with practices that GAO has found enhance and sustain agency collaboration.

question: How have the VA and IHS measured their progress toward the MOU's goals?
answer: The agencies have also developed three metrics aimed at measuring progress toward the MOU's goals.
child_questions: question: To what extent have these metrics been effective?
answer: However, two of the three metrics are inadequate because their connection to any specific MOU goal is not clear and, while they include quantitative measures that tally the number of programs and activities increased or enhanced as a result of the MOU, they lack qualitative measures that would allow the agencies to assess the degree to which the desired results are achieved.
child_questions: question: What are the potential risks of using inadequate metrics?
answer: The weaknesses in these metrics could limit the ability of VA and IHS managers to gauge progress and make decisions about whether to expand or modify their programs and activities.

questions: question: Why do VA and IHS face challenges in consulting with tribes to implement the MOU?
answer: VA and IHS face unique challenges associated with consulting with a large number of diverse, sovereign tribes to implement the MOU, and lack fully effective processes to overcome these complexities. VA and IHS officials told us the large number (566 federally recognized tribes) and differing customs and policy-making structures present logistical challenges in widespread implementation of the MOU within tribal communities.
child_questions: question: Why does the nature of tribal governance cause particular complexity?
answer: They also told us that tribal sovereignty--tribes' inherent right to govern and protect the health, safety, and welfare of tribal members--adds further complexity because tribes may choose whether or not to participate in MOU-related activities.

question: How do VA and IHS consult with tribes on MOU-related activities?
answer: Consistent with internal controls, VA and IHS have processes in place to consult with tribes on MOU-related activities through written correspondence and in-person meetings.
child_questions: question: To what extent are these processes effective?
answer: However, according to tribal stakeholders GAO spoke with, these processes are often ineffective and have not always met the needs of the tribes, and the agencies have acknowledged that effective consultation has been challenging.
child_questions: question: What are some examples of ineffective communication, according to tribal stakeholders?
answer: For example, one tribal community expressed concern that agency correspondence is not always timely because it is sent to tribal leaders who are sometimes not the tribal members designated to take action on health care matters. Similarly, some tribal stakeholders told GAO that the agencies have not been responsive to tribal input and that sometimes they simply inform tribes of steps they have taken without consulting them.

question: What are some steps that VA and IHS have taken to address these concerns?
answer: VA and IHS have taken steps to improve consultation with tribes. For example, VA has established an Office of Tribal Government Relations, through which it is developing relationships with tribal leaders and other tribal stakeholders. Additionally, in Alaska, VA has been consulting with a tribal health organization for insight on reaching tribes. However, given the concerns raised by the tribal stakeholders GAO spoke with, further efforts may be needed to enhance tribal consultation to implement and achieve the goals of the MOU.

questions: question: What populations are eligible for healthcare services from both VA and IHS?
answer: Native Americans who have served in the military may be eligible for health care services from both VA and IHS.

question: What was the purpose of the MOU for VA and IHS?
answer: To enhance health care access and the quality of care provided to Native American veterans, in 2010, these two agencies renewed and revised an MOU designed to improve their coordination and resource sharing related to serving these veterans.
child_questions: question: What was GAO's role in this review process?
answer: GAO was asked to examine how the agencies have implemented the MOU.

questions: question: What does this report examine?
answer: This report examines: (1) the extent to which the agencies have established mechanisms through which the MOU can be implemented and monitored; and (2) key challenges the agencies face in implementing the MOU and the progress made in overcoming them.

question: How did GAO conduct this work?
answer: To conduct this work, GAO interviewed VA and IHS officials and reviewed agency documents and reports.
child_questions: question: What role did tribal stakeholders play in the report?
answer: GAO also obtained perspectives of tribal communities through attendance at two tribal conferences; interviews with tribal leaders and other tribal members, including veterans; and interviews with other stakeholders, such as health policy experts and consultants.