The number of AI/AN veterans eligible for both VA and IHS services is unknown. The U.S. Census Bureau estimates that in 2017 approximately 141,000 AI/AN individuals identified themselves as veterans. This estimate includes only individuals who identified as AI/AN alone and not in combination with another racial group. IHS and VA do not have an administrative mechanism for determining the number of AI/AN veterans who are users of both systems. Instead, each agency separately relies on individuals to identify either as veterans, or as AI/AN, resulting in different counts. Specifically, according to IHS, in fiscal year 2017, 48,169 active IHS users self-identified as veterans. According to VA, in fiscal year 2017, 80,507 VA-enrolled veterans self-identified as AI/AN. VA is charged with providing health care services to the nation’s eligible veterans, and served 6.8 million veterans in fiscal year 2017 with a total health care budget of about $69 billion. VA’s health care system includes 18 regional networks—Veterans Integrated Service Networks—to which each of VA’s facilities is assigned. VA has 170 medical centers, which offer a variety of inpatient and outpatient services, ranging from routine examinations to complex surgical procedures. VA’s health care system also includes community-based outpatient clinics and other facilities that generally limit services to primary care and some specialty care. When needed services are not available at VA facilities or within required driving distances or time frames, VA may purchase care from non-VA providers through its community care programs, such as the Veterans Choice Program. Eligibility for VA health care is based on several factors, including the veteran’s period of active service, discharge status, the presence of service connected disabilities or exposures, income, and other factors. VA uses factors such as these to categorize eligible veterans into eight enrollment priority groups—established to manage the provision of care. Some veterans qualify for free health care services based on service connected disabilities, income, or other special eligibilities, while others may be responsible for co-payments. IHS was established to provide health services to members of AI/AN tribes, and its facilities are primarily in rural areas on or near reservations. IHS’s fiscal year 2017 budget was approximately $5 billion, and the agency served about 1.6 million individuals. The agency is organized into 12 federally designated geographic areas. IHS provides services directly through a federally operated network of 25 hospitals, 53 health centers, and 30 health stations in 37 U.S. states. In addition, about 54 percent of IHS’s funds are provided to THPs to operate about 580 of their own facilities such as hospitals, health centers, clinics and health stations. IHS also provides funding to 41 nonprofit organizations through the Urban Indian Health program to provide health care services to AI/AN individuals living in urban areas. IHS and THP facilities are often limited to providing primary and emergency care services. When needed health care services are not available at IHS or THP facilities, in certain circumstances the facilities may pay external providers to provide these services through IHS’s Purchased/Referred Care (PRC) program. Before the PRC program can provide payment, patients must exhaust all health care resources available to them from private insurance, state health programs, and other federal programs, including VA. Furthermore, eligibility for PRC payment is not automatic, and IHS has reported that PRC funds are not sufficient to pay for all necessary care and, therefore, generally pay for only the highest priority costs, such as emergency care and transportation to that care. To be eligible for IHS health care services, an individual must generally be a member or descendant of one of the current 573 federally recognized Indian tribes, as evidenced by such factors as tribal membership, enrollment, residence on tax-exempt land, ownership of restricted property, active participation in tribal affairs, or other relevant factors. In instances where an AI/AN veteran is eligible for a particular health care service from both VA and IHS, VA is the primary payer. The 2010 MOU between VA and IHS set mutual goals and objectives to facilitate coordinating and resource-sharing between the two agencies. Specifically, the five MOU goals are as follows: 1. Increase access to and improve quality of health care and services to the mutual benefit of both agencies. Effectively leverage the strengths of the VA and IHS at the national and local levels to afford the delivery of optimal clinical care. 2. Promote patient-centered collaboration and facilitate communication among VA, IHS, AI/AN veterans, tribal facilities, and Urban Indian clinics. 3. In consultation with tribes at the regional and local levels, establish effective partnerships and sharing agreements among VA headquarters and facilities, IHS headquarters and facilities, tribal facilities, and Urban Indian Health Programs in support of AI/AN veterans. 4. Ensure that appropriate resources are identified and available to support programs for AI/AN veterans. 5. Improve health promotion and disease prevention services to AI/AN veterans to address community-based wellness. In accordance with these five goals, the MOU contains specific areas in which VA and IHS agreed to collaborate and coordinate, including: Reimbursement: development of payment and reimbursement policies and mechanisms to support care delivered to dually eligible AI/AN veterans. Sharing staff: sharing of specialty services, joint credentialing and privileging of health care staff, and arranging for temporary assignment of IHS Public Health Service commissioned officers to VA. Staff training: providing systematic training for VA, IHS, THP, and Urban Indian Health Program staff on VA and IHS eligibility requirements to assist them with appropriate referrals for services. Information Technology Interoperability: interoperability of systems to facilitate sharing of information on common patients, and establishment of standard mechanisms for VA, IHS, and THP providers to access records for patients receiving care in multiple systems. VA and IHS each designated certain staff to oversee and implement the MOU, but VA is generally responsible for administering the MOU. For example, VA’s Office of Community Care provides oversight of the reimbursement agreements—which are a key part of the MOU. Within that office, VA established the IHS/THP Reimbursement Agreements Program to carry out portions of the MOU related to the development of payment and reimbursement policies. Under these policies, in instances where an AI/AN veteran is eligible for a particular health care service from a VA facility, that veteran can instead receive the eligible service at an IHS or THP facility without prior VA approval and, under a reimbursement agreement, VA will reimburse the facility for the service. Some key aspects of the reimbursement agreement program are as follows: All IHS facilities are covered under one national reimbursement agreement between VA and IHS. THPs each negotiate their own separate reimbursement agreements with VA. While VA uses a reimbursement agreement template based on the agreement with IHS, the terms of each THP agreement may deviate from those in IHS’s national agreement. Urban Indian Health Programs are generally not eligible for reimbursement agreements. VA provides reimbursement for outpatient and inpatient direct care services provided at IHS and THP facilities. VA also reimburses IHS and THP facilities for costs of outpatient prescriptions for AI/AN veterans, as well as filling prescriptions for AI/AN veterans served at IHS and THP facilities through VA’s Consolidated Mail Outpatient Pharmacy program. VA does not provide reimbursement for those services from external providers paid for by IHS or THP PRC programs. VA reports that the process of establishing reimbursement agreements with THPs has multiple phases. The process begins with initial communication between the THP and VA, followed by an orientation briefing. The THP then begins to draft the agreement (based on VA’s template) and prepare required VA paperwork (e.g., an implementation plan and proof of certification or accreditation). Once drafted, the THP submits the draft agreement and paperwork for review by VA’s IHS/THP Reimbursement Agreements Program, followed by review by a VA contracting officer and legal team. The agreement is complete once it is signed by VA and the THP. A joint leadership team of VA and IHS officials continues to oversee the implementation of the 2010 MOU through meetings, regular reporting, and the establishment of goals and measures to assess performance— but these measures lack targets for assessing progress toward the goals. VA and IHS officials also told us they are drafting a revised MOU to be broader and more flexible than the existing MOU and are updating the performance measures. However, officials have not indicated that any revised measures will include targets. Since our last report in 2014, a joint national leadership team comprised of VA and IHS officials has continued to use quarterly meetings, routine reporting, and MOU goals and measures to oversee MOU implementation and help facilitate collaboration. VA and IHS officials told us that the leadership team consists of officials in VA’s Office of Rural Health and Office of Tribal Government Relations, and the IHS Deputy Director for Intergovernmental Affairs. Specifically, the leadership team has met to discuss the progress and status of the MOU, develop implementation policy and procedures, create performance measures and timelines, and evaluate progress on those measures. The leadership team also compiles annual reports on progress in MOU implementation that includes information about activities and challenges on meeting MOU goals using established measures, and information on the reimbursement agreements and outpatient pharmacy program. In addition, VA and IHS issue monthly data reports on the reimbursement agreements, including the total amount disbursed, the number of veterans receiving services reimbursed by VA, and the number of claims processed for IHS and THP facilities. The leadership team receives input from workgroups tasked with the responsibility for implementing and developing strategies to address the goals of the MOU. The workgroups primarily consist of VA and IHS staff who meet periodically to discuss goals and report quarterly to the leadership team. Tribal officials have participated in some MOU workgroups, though they are not a part of the MOU leadership team. Since our last report in 2014, the number of workgroups decreased from 12 to three groups. (See table 1.) VA and IHS officials said that there were a number of reasons why the number of workgroups had decreased over time, such as consolidation into broader groups because the missions of some groups were similar. VA officials noted that the 12 original workgroups reflected the structure of the MOU, but over time they realized that there was not a need for workgroups in some of these areas. With the establishment of the MOU, VA and IHS have been able to share resources and collaborate on activities to improve access of care for AI/AN veterans. VA and IHS reported that the MOU has helped both agencies develop an outpatient pharmacy program for AI/AN veterans, hold joint training and recruitment events, and establish the reimbursement agreement program, among other accomplishments. The VA, IHS, and THP facility officials we spoke with noted activities related to the reimbursement agreements and a few noted improvements in areas such as training and telehealth as a result of the MOU. However, most of the facility officials generally reported they had not observed improvements in national-level VA and IHS collaboration and coordination in other areas identified by the MOU. Additionally, these facility officials told us that their facilities have not implemented any new policies, procedures, or any specific facility performance goals or targets that were linked to the MOU. VA and IHS headquarters officials acknowledged that all areas of the MOU have not been implemented at all facilities, and noted that while improvements have been made in many areas, organizational challenges remain, such as in the area of information technology. One IHS headquarters official added that even though VA and IHS have not fully implemented all parts of the MOU, they have addressed each area of the MOU in some manner. For example, one of the goals of the MOU is to improve coordination of care by developing and testing innovative approaches and disseminating best practices. IHS headquarters officials indicated that the agency has addressed this goal in part by creating an Improving Patient Care program that was informed by using VA curriculum and utilizing lessons learned from VA’s Patient Aligned Care Teams. VA and IHS leadership said they are currently in the process of revising the MOU to be broader and more flexible to better meet the care needs of AI/AN veterans. Regularly monitoring and updating written agreements on collaboration, such as the MOU, is consistent with our key collaboration practices. IHS officials said that in contrast to the current MOU, in the new MOU, they are not looking to delineate every area of coordination and instead are grouping topics into broader areas of coordination. In the fiscal year 2017 MOU annual report, VA and IHS noted they were removing outdated language from the MOU and planned to create a more comprehensive, flexible MOU that would serve both agencies well into the future. VA and IHS officials indicated that these revisions will address some areas in the current MOU that they have not yet been able to implement. In June 2018, VA officials said that the leadership team had decided upon a revised set of MOU goals and associated objectives. In February 2019, VA and IHS reported that the target completion date for the new MOU was spring 2020. VA and IHS have improved their efforts to measure progress towards meeting the five MOU goals since 2014. In response to a recommendation made in our April 2013 report, VA and IHS revised their MOU performance measures in 2015—better aligning the measures with the MOU goals. In addition, as a result of our work in 2013, the agencies revised an existing data collection reporting template used to gather information for each measure—such as the measurable objective, rationale and intent of the measures, action plan, milestones, and barriers—to help determine whether MOU goals were being met. While we found that the three existing MOU workgroups had since stopped using this template, a VA official confirmed that they believe relevant information is still captured through its monthly and quarterly reports. Nonetheless, while VA and IHS improved their performance measurement efforts since our 2013 report, we found that the revised MOU performance measures still do not have quantitative and measurable targets to assess agency progress toward the goals. We have previously reported that performance measures should have numerical targets or other measurable values, which help assess whether overall goals and objectives were achieved by easily comparing projected performance and actual results. Besides having measureable targets, other key attributes of successful performance measures include linkage to an agency’s goals and mission, clarity, objectivity, and balance. None of the 15 revised measures have targets against which performance can be measured to assess progress and evaluate effectiveness. (The results of our assessment are shown in table 2.) For example, while the number of shared VA-IHS trainings and webinars is a performance measure, there is no target for the number of shared trainings VA and IHS hope to complete each year. VA officials we spoke with stated VA has not considered adding targets to these measures, noting that the nature of the measures and MOU work against establishing targets. For example, officials said that the measures related to the reimbursement agreements are dictated by the needs of the population seeking health care and the providers at the IHS and THP facilities. VA officials we spoke with said instead of targets, they assess success or failure by whether they see incremental growth in the measures. Officials added that they examine these measures quarterly to determine if they have increased, decreased, or remained stable. If the measures are stable or decrease, officials said they consider if these trends can be reversed. However, the absence of targets limits the ability of VA and IHS to use these measures to assess performance. Without defined measurable targets or goals, VA and IHS lack a clear basis for objectively and strategically evaluating how and where improvements should be made. For example, while it is helpful to count the number of tribal outreach activities conducted, setting an annual target for such activities would allow the agencies to better assess whether they are meeting their goals in this area. In addition, some of these measures also lacked other attributes important for assessing performance. Specifically, five of the measures listed the completion of an annual metric review, which is a task to execute rather than a desired performance outcome to be measured. VA and IHS also are not using two measures. Specifically, they have not collected any data to track results on the number of VA and IHS employees who attend training and on the quality of health care provided. Relatedly, for the measure on health care quality, VA and IHS have not developed a clear definition against which to measure performance, as specific quality measures have not been determined and data are not being collected. VA and IHS have documented challenges related to confusion and difficulty in tracking some measures; for example, at a meeting in March 2017, the MOU leadership team discussed that measures were not well tailored to the workgroup structure at that time. IHS officials also acknowledged that the measures currently in place are counting activities, but not necessarily always measuring performance—such as whether trainings held were effective. VA officials said that revising the MOU will give them an opportunity to revisit the performance measures used, and that they are looking to apply lessons learned to do a better job in the future at defining the measures. Similarly, IHS officials noted that the agencies are engaged in conversation about the performance measures to make them more useful. However, as previously noted, VA officials said that they have not considered establishing targets for the measures. THP facilities’ use of reimbursement agreements with VA increased from 2014 through 2018. The selected IHS and THP facilities we spoke with viewed the reimbursement agreements as beneficial, but also identified some concerns. The use of VA’s reimbursement agreements with THPs increased from 2014 through 2018, as measured by the number of agreements, claims reimbursed, and veterans served. In addition, there was also an increase in payments made for prescriptions filled through the VA’s Consolidated Mail Outpatient Pharmacy program for AI/AN veterans receiving services at IHS and THP facilities. As all IHS facilities are covered under a single national agreement that was instituted prior to 2014, there was less change in the use of reimbursement agreements by these facilities. Reimbursement agreements entered. The number of reimbursement agreements with THPs more than doubled from 2014 to 2018, increasing about 113 percent. We previously reported, as of May 16, 2014, that VA had 53 reimbursement agreements with THPs. VA data showed that as of December 2018 it had 113 reimbursement agreements with THPs, representing about 34 percent of the 337 total IHS-funded THPs. (See fig. 1.) VA also reported that there were 42 additional pending reimbursement agreements with THPs that were in varying phases of submission, processing, and review. In addition, as in 2014, IHS facilities are covered under a single national agreement, and the number of IHS facilities covered by it has remained similar. In 2014, we reported that VA officials had conducted outreach through tribal letters and events to educate THPs about the option of establishing reimbursement agreements, and officials told us this outreach has continued. As we reported previously, there are several reasons a THP might decide not to have an agreement with VA, such as deciding it was not worth the time and resources needed to establish an agreement. Officials from a national tribal organization we spoke with said that smaller tribes without many veterans or resources may not be interested. IHS officials also noted that if a THP’s veteran population has alternate payment resources (e.g., Medicaid or private insurance), it may not be worth the steps to implement a reimbursement agreement if the THP will not be billing VA for veterans’ services. Amount of claims reimbursed. In fiscal year 2014, VA paid IHS and THP facilities $11.5 million for services provided to AI/AN veterans, which grew to $20.1 million in fiscal year 2018. This increase mainly represents the growth in reimbursement to THP facilities—which grew 181 percent, from $4.3 million in fiscal year 2014 to $12.1 in fiscal year 2018. During this same time period, reimbursements to IHS facilities remained relatively stable, reflecting the stable number of IHS facilities receiving reimbursements. (See fig. 2.) Veterans served. Between fiscal year 2014 and fiscal year 2018, according to VA data, the number of unique AI/AN veterans receiving services reimbursed by VA each year has increased from about 3,800 in 2014 to a high of nearly 5,300. (See fig. 3.) While IHS facilities accounted for a larger percentage of veterans with reimbursed services compared to THPs, the number of veterans receiving services reimbursed by VA at THPs increased significantly. For fiscal year 2014, 2,965 AI/AN veterans received services reimbursed by VA at IHS facilities, which decreased slightly to 2,829 in fiscal year 2018. In comparison, 885 veterans received services reimbursed by VA at THP facilities in fiscal year 2014, which nearly tripled to 2,531 veterans in fiscal year 2018. Prescriptions filled. Similar to increases in the numbers of AI/AN veterans served under the reimbursement agreements, AI/AN veterans’ utilization of VA’s Consolidated Mail Outpatient Pharmacy program has also increased. Prescriptions filled through this program more than doubled—from more than 440,000 prescriptions in fiscal year 2014 to nearly 886,000 prescriptions in fiscal year 2018. (See fig. 4.) VA and IHS annual reports indicate that the pharmacy program has been one of the most successful collaborations between VA and IHS for AI/AN veterans, providing more than 2 million prescriptions for VA-IHS patients since the pharmacy program collaboration began in 2010. While this program was originally limited to AI/AN veterans served at IHS facilities, in December 2016, VA and IHS entered into an Interagency Agreement that extended the program to THPs. Officials from the majority of IHS and THP facilities we contacted said they were generally pleased with the reimbursement agreements. Among those, officials from one THP noted that the revenue received from their reimbursement agreement freed up other resources that allowed them to hire an additional part-time worker to conduct VA outreach activities. Additionally, a representative of a national tribal organization noted that IHS and THP facilities’ funding is limited and this revenue helps them extend services to eligible AI/AN veterans. However, officials from a number of IHS and THP facilities also had concerns about the agreements, including the lack of reimbursement for PRC program services provided by IHS and THP facilities, the length of time it took to enter into the agreements, and the time frames of the agreements: Lack of reimbursement for PRC program services. Officials at most IHS and THP facilities we contacted said they believed VA should reimburse facilities for services from external providers paid through the PRC program. Officials at some facilities said they have had to deny PRC services due to a lack of program funds. According to some facility and IHS area office officials, this issue is particularly relevant in states where Medicaid was not expanded under the Patient Protection and Affordable Care Act (PPACA). In states where Medicaid eligibility was expanded, more AI/AN individuals may therefore be eligible for Medicaid—potentially freeing up PRC funds. For example, an IHS official noted that prior to Medicaid expansion in his state they would have to limit PRC funds to be used only in life or death scenarios after May or June of each year, but that currently his facility was not limiting any PRC services. Given the limitations in PRC program funds, officials from a national tribal organization and some THPs noted they have raised the possibility of including the PRC program in the reimbursement agreements with VA, although the program was ultimately not included. VA officials noted that there is no statutory requirement for them to include the PRC program in the reimbursement agreements and also identified several other reasons for not including it. For example, they said that VA does not want to pay for services externally that it already offers internally and that it would prefer to coordinate the patient’s care within VA’s existing programs, such as VA’s own programs for purchasing care from external providers—like the Veterans Choice Program. The length of time to enter into an agreement. Officials from a few THP facilities and one national tribal organization we spoke with noted concerns about the amount of time it took to enter into reimbursement agreements. Our analysis of VA reimbursement agreement data shows that the median amount of time that it took to enter an agreement with THPs was over 1 year (about 403 days). We found that the number of days from the first contact by a THP to the actual signing of the agreement ranged from 96 days (over 3 months) to 1,878 days (more than 5 years). According to VA records and interviews, there were reasons for delays in completing reimbursement agreements, including lengthy negotiations, incomplete submission of information from the THPs, lapses in communication between VA and the THP, and a THP’s lack of medical certification or accreditation. VA officials explained that the amount of time increases if the THP does not want to use the VA-approved reimbursement agreement template or wants to change the terms of the agreement. For example, an official from one THP facility said that it took 2.5 years to finalize its reimbursement agreement due, in part, to internal challenges with their legal counsel and external challenges with negotiating the terms of the agreement during a time when the VA was developing a national reimbursement agreement template. VA officials also explained that entering the agreement with IHS was simpler than entering agreements with THPs because it was a national agreement between two federal agencies and, for example, did not require having a contracting officer review the agreement—an extra step needed for agreements with non-federal agencies. The length of time reimbursement agreements are in effect. Officials from a few THP facilities expressed a desire for longer reimbursement agreements that would permit greater planning ability. The agreement between VA and IHS was initially set for 3 years. It was then extended twice, once for 2 years and once for 1.5 years. The time frames for THP agreements have generally been extended consistent with extensions to the national agreement. Officials from one THP we spoke with said that having short-term reimbursement agreements causes problems with internal organizational planning and it would be beneficial to have a longer term non-expiring agreement that can be cancelled so that THPs do not continue to expend resources to complete new agreements or amendments every 2 years. In June 2018, VA and IHS signed an amendment to extend the terms of the national reimbursement agreement through June 30, 2022. VA officials said they are currently in the process of working with THPs to similarly extend their agreements. In speaking to officials at selected VA, IHS, and THP facilities about key issues related to coordinating care for AI/AN veterans, we found that the extent of coordination they reported varied widely. For example, three IHS and THP facilities said they had little to no care coordination with their local VA partners; noting, for example, that they rarely refer veterans to VA since they offer more services than the closest VA facilities. Other facilities described more extensive and formalized care coordination, including shared funding of certain VA and THP employees, or VA employees on site at THP facilities to manage veterans’ care and referrals to and from VA. In Alaska, for example, where services offered by VA are very limited, VA instead has formal sharing and reimbursement agreements established with 26 THPs, which provide the majority of services to AI/AN veterans, as well as some non-Native veterans. Two of the THP facilities we spoke with in Alaska have VA employees working on site to help coordinate veterans’ care. VA and IHS headquarters officials indicated that the MOU was intended to allow for variation in the level of coordination at the local, facility level not to create demands or obligations on facilities. One VA official noted that as the new MOU is developed, both VA and IHS want to continue to allow VA, IHS, and THP facilities to engage in whatever level of coordination makes sense. Despite variation in the extent of coordination, officials identified several common challenges regarding coordination between local VA, IHS, and THP facilities: Referring patients to VA facilities. Officials from 9 of the 15 VA, IHS, and THP facilities we contacted reported conflicting information about the process for referring AI/AN veterans from IHS and THP facilities to VA facilities for specialty care. For example, 4 of the IHS and THP facilities we spoke with said that AI/AN veterans generally could not be referred directly to VA specialty care by IHS or THP providers without first being seen and referred by a provider at VA. These facility officials indicated that this practice was a barrier to care. These officials also noted that this could result in the patient receiving, and the federal government paying for, duplicative tests. However, officials at another IHS facility indicated that IHS and THP facilities should be able to refer patients directly to VA specialty care. Additionally, during an interview at a VA facility, local and regional officials had differing understandings of whether IHS and THP facilities could refer patients directly to VA specialty care. VA and IHS headquarters officials both reported that in general, IHS or THP facilities cannot refer a patient to VA specialty care without that patient first being seen in VA primary care. However, VA officials reported that there is no national policy or written guidance on how to refer patients from an IHS or THP facility to a VA facility. VA officials said that the coordination process is left to the local VA facility and the respective IHS or THP facilities and the process can vary from one facility to another— explaining why differing information was reported by facility officials. Our past work on interagency collaborative mechanisms identifies that it is a leading collaboration practice to have written guidance and agreements to document how agencies will collaborate. Without a written policy or guidance about how referrals of AI/AN veterans from IHS and THP facilities to VA facilities may be managed, VA and IHS cannot ensure that VA, IHS, and THP facilities have a consistent understanding of the options available for these referrals. Information technology interoperability and access. Officials at 10 of the 15 VA, IHS, and THP facilities we contacted cited challenges related to accessing each other’s health information technology systems. Most stated that a lack of interoperability of their electronic health records caused challenges, while a few IHS and THP facilities also mentioned that the lack of access to VA systems makes it difficult to verify a veteran’s eligibility or determine the services for which VA will reimburse. For example, one THP noted that if an AI/AN veteran was sent to VA for a service, the THP provider would not receive the veteran’s follow-up records as quickly as if they had access to each other’s systems. Improving systems’ interoperability was a focus area identified in the MOU, and an IHS official indicated that while the agencies had some initial work on the topic, no systematic solutions were identified. We have previously identified VA’s lack of systems interoperability—particularly with the Department of Defense—as a contributor to the agency’s challenges related to health care. VA and IHS officials identified some potential workarounds to this lack of interoperability, although they noted that some of the described workarounds could be time consuming and may not be feasible for all facilities: An IHS headquarters official said that IHS and VA each have the ability to request the sharing of information from an individual electronic health record held by the other agency through secure emails—although the official noted that this is not as fast or efficient as being able to log in to each other’s systems. VA officials also reported that VA belongs to the eHealth Exchange— a national health information exchange—and said that IHS or THPs could join that, through which they would be able to access information about common veteran patients. However, IHS reported that although the agency explored connecting to the eHealth Exchange several years ago, testing and onboarding costs to participate were prohibitive. IHS noted that several individual facilities across the IHS system have elected to invest in connections with regional health information exchanges. Similarly, two THPs we spoke with reported being a part of other, more locally-based health information exchanges, but noted that VA was not part of these exchanges. A VA official noted that there is an enrollment guide that details how enrollment and eligibility verification will be managed between IHS, THP, and VA facilities. This guide describes how IHS or THP facilities can request veterans’ enrollment and eligibility information from the VA Health Eligibility Center using a templated spreadsheet that sends requests via email through a secure data transfer service. VA’s Health Eligibility Center verifies the list and returns the completed enrollment/eligibility excel spreadsheet to the IHS or THP facility securely. IHS and THP facilities can also contact the VA Health Eligibility Center directly by telephone for fewer than five veterans per call, or their local VA medical center by telephone to verify one AI/AN veteran’s enrollment and eligibility per call. IHS or THP facilities could also enter an arrangement with a local VA facility to have VA employees or co-funded employees on site at IHS or THP facilities, or to have VA-credentialed employees that can access VA systems to share information. However, these options may not be systemic solutions that work at all facilities. An IHS headquarters official noted, for example, that not all IHS or THP facilities have the type of relationship with their local VA facility that would lead to the establishment of such arrangements. In terms of the potential for improving interoperability in the future, VA is in the process of implementing a new electronic health record system, and we have previously reported that VA has identified increased interoperability as a key expected outcome of its decision to switch systems. Officials from two VA and THP facilities were hopeful that this new system will help improve interoperability since some THPs use an electronic health record system from the same company that VA has a contract with. Additionally, an IHS headquarters official said that IHS is also reevaluating its information technology platform and one requirement of any new IHS system will be to enhance interoperability with VA, pending the funding to do so. IHS also reported that the agency will consider health information exchange participation as part of the agency’s information technology modernization efforts. Staff turnover. Officials from 9 of 15 facilities identified staff turnover at VA, IHS, and THP facilities as an impediment to having better or consistent coordination. VA, IHS, and THP facility officials described situations in which the coordination between facilities was dependent on specific staff or facility leadership. According to officials, when there was turnover among these staff or positions went unfilled, or were eliminated, the coordination decreased or came to a halt. For example, officials at one VA facility said that they have found that if a sitting tribal government expresses interest in VA collaboration, they have to act quickly and work with the tribe before there is turnover and new tribal leadership comes in with different priorities. Additionally, officials from one IHS facility described a situation in which they had previously coordinated with their local VA facility through that facility’s AI/AN liaison. However, the coordination lapsed when the liaison left VA and the position went unfilled. Similarly, a THP official stated that coordination with VA was previously led by a nurse case manager on site who was a joint VA and THP employee. The official said that since that person’s retirement, she did not know who to contact at VA to coordinate veterans’ care. Officials at one IHS facility noted that due to turnover and attrition they would like to see more education for front line staff at both IHS and VA, so they can more efficiently obtain care for patients at the VA. VA headquarters officials acknowledged that staff turnover and retraining is a challenge that they will need to continually address as the MOU is carried out. In our prior work related to IHS and VA, we have found that both agencies face challenges related to staff turnover and training. VA Co-Payments. Officials at 3 of the 11 IHS and THP facilities we contacted, as well as IHS headquarters officials and representatives of two national tribal organizations said that the copayments that VA charges veterans represented a barrier to AI/AN veterans receiving care. While AI/AN veterans do not have any cost-sharing for care provided at IHS or THP facilities, they are subject to the same copayments as other veterans when they receive care from VA facilities. VA data shows, for example, that of the 80,507 VA-enrolled self-identified AI/AN veterans in in fiscal year 2017, about 30 percent were charged copayments, averaging about $281.56 billed per veteran. Officials from one THP noted that this kind of financial liability may discourage AI/AN veterans from getting care at VA, or lead them to return to the THP after they realize they will have to pay for care at VA. While some of our interviewees suggested that VA should waive copayments for AI/AN veterans, a VA official said they do not have the legal authority to do this. The official said that their statute specifies the categories of veterans for which they must charge copayments and VA is not authorized to waive the copayments for AI/AN veterans on the basis of their AI/AN status without statutory exemptions. While certain AI/AN veterans may qualify for waived copayments based on their inclusion in other statutory categories, AI/AN veterans are not specifically listed as a category for which copayments can otherwise be waived. VA officials also cautioned that because AI/AN veterans may qualify for waived copayments through these other categories, the possibility of copays should not discourage IHS or THP facilities from referring AI/AN veterans to VA. Since 2014, VA and IHS have continued to work together to oversee and implement their MOU aimed at improving the health care provided to dually eligible AI/AN veterans. While the agencies have made progress in certain areas of the MOU, especially those related to reimbursement, other parts have seen less attention. VA and IHS are now updating the MOU, and plan to revisit the related performance measures. This gives the agencies an opportunity to evaluate how well their existing oversight mechanisms have been working, and to improve these mechanisms accordingly in the future. Regardless of these updates, the agencies need to have effective performance measures. While the agencies took steps to improve MOU performance measures in response to one of our prior reports, these steps were not sufficient and the measures they set lack important attributes, including measurable targets. VA and IHS have indicated that they plan to reevaluate performance measures as they update the MOU, but have not indicated that these new measures will identify targets. Absent targets, VA and IHS are limited in their ability to measure progress towards MOU goals and ultimately make strategic decisions about how and where improvements should be made. At the local level, care for AI/AN veterans relies on coordination among individual VA, IHS, and THP facilities. However, variations in relationships among these many facilities and staff turnover creates challenges, which heightens the importance of clear and consistent guidance from the national level. Yet no written guidance exists related to referring AI/AN veterans to VA facilities for specialty care. Without such guidance, VA and IHS cannot ensure that facilities have a consistent understanding of the available referral options for AI/AN veterans. Enhancing their guidance in this area will help VA and IHS ensure that AI/AN veterans have access to needed care. We are making a total of three recommendations, including two to VA and one to IHS. Specifically: As VA and IHS revise the MOU and related performance measures, the Secretary of Veterans Affairs should ensure these measures are consistent with the key attributes of successful performance measures, including having measurable targets. (Recommendation 1) The Secretary of Veterans Affairs should, in consultation with IHS and tribes, establish and distribute a written policy or guidance on how referrals from IHS and THP facilities to VA facilities for specialty care can be managed. (Recommendation 2) As VA and IHS revise the MOU and related performance measures, the Director of IHS should ensure these measures are consistent with the key attributes of successful performance measures, including having measurable targets. (Recommendation 3) We provided a draft of this report to VA and the Department of Health and Human Services for review and comment. We have reprinted the comments from VA in appendix I and the comments from the Department of Health and Human Services in appendix II. Both departments concurred with our recommendations. The Department of Health and Human Services also provided technical comments, which we incorporated as appropriate. In response to our recommendations to ensure revised performance measures include key attributes of successful performance measures, VA and the Department of Health and Human Services provided information about the process for finalizing the new MOU, including conducting tribal consultation. They noted that VA and IHS will work together to ensure that performance measures under the new MOU include appropriate measurable targets. Regarding our recommendation to VA about establishing and distributing a written policy or guidance on how referrals from IHS and THP facilities to VA facilities for specialty care can be managed, VA noted the Office of Community Care is working on a process to enhance care coordination among all VA and non-VA providers—including IHS and THP providers. VA noted that for IHS and THPs, this will include establishing forms and procedures to refer patients to VA for specialty care, and that VA will provide training to applicable staff once the process and procedures are finalized. VA also noted that it is in the process of establishing an advisory group that will include tribal, IHS, and VA representation, and will make recommendations related to care coordination guidance and policies. The target completion date for establishing this group is spring 2020. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the Secretaries of VA and the Department of Health and Human Services, and other interested parties. In addition, the report will be available at no charge on GAO’s website at http://www.gao.gov/. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or farbj@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix III. In addition to the contact named above, Kathleen M. King (Director), William Hadley (Assistant Director), Christina Ritchie (Analyst-in-Charge), Jennie Apter, Shaunessye D. Curry, Jacquelyn Hamilton, and Vikki Porter made key contributions to this report.

Summary: A 2010 MOU set mutual goals for VA and IHS collaboration and coordination related to serving AI/AN veterans. Under this MOU, VA has established reimbursement agreements with IHS and tribal health programs to pay for care provided to AI/AN veterans. In 2013 and 2014, GAO issued two reports on VA and IHS implementation and oversight of the MOU. GAO was asked to provide updated information related to the agencies' MOU oversight. This report examines (1) VA and IHS oversight of MOU implementation since 2014, (2) the use of reimbursement agreements to pay for AI/AN veterans' care since 2014, and (3) key issues identified by selected VA, IHS, and tribal health program facilities related to coordinating AI/AN veterans' care. To conduct this work, GAO reviewed VA and IHS documents, reports, and reimbursement data from 2014 through 2018. GAO interviewed VA and IHS officials at the headquarters level, and officials at 15 VA, IHS, and tribal facilities in four states—Alaska, New Mexico, North Carolina, and Oklahoma—selected based on factors including the number of reported AI/AN veterans served, and geographic diversity. GAO also interviewed organizations representing tribes and tribal health programs. The Department of Veterans Affairs (VA) and the Department of Health and Human Services' (HHS) Indian Health Service (IHS) established a memorandum of understanding (MOU) to improve the health status of American Indian and Alaska Native (AI/AN) veterans through coordination and resource sharing among VA, IHS, and tribes. Since GAO's last report on the topic in 2014, VA and IHS have continued to jointly oversee the implementation of their MOU—for example, through joint workgroups and quarterly meetings and reports—but they lack sufficient measures for assessing progress towards MOU goals. Specifically, while the agencies established 15 performance measures, they did not establish targets against which performance could be measured. For example, while the number of shared VA-IHS trainings and webinars is a performance measure, there is no target for the number of shared trainings VA and IHS plan to complete each year. GAO's work on best practices for measuring program performance has found that measures should have quantifiable targets to help assess whether goals and objectives were achieved by comparing projected performance and actual results. VA and IHS officials said they are currently in the process of revising the MOU and updating the performance measures used. However, officials have not indicated that any revised measures will include targets. Total reimbursements by VA for care provided to AI/AN veterans increased by about 75 percent from fiscal year 2014 to fiscal year 2018. This increase mainly reflects the growth in reimbursement from VA to tribal health program facilities—facilities that receive funding from IHS, but are operated by tribes or tribal organizations. Similarly, the number of VA's reimbursement agreements with tribal health programs and the number of AI/AN veterans served under the reimbursement agreements also increased during this period. The VA, IHS, and tribal facility officials GAO spoke with described several key challenges related to coordinating care for AI/AN veterans. For example, facilities reported conflicting information about the process for referring AI/AN veterans from IHS or tribal facilities to VA, and VA headquarters officials confirmed that there is no national policy or guide on this topic. One of the leading collaboration practices identified by GAO is to have written guidance and agreements to document how agencies will collaborate. Without a written policy or guidance about how referrals from IHS and tribal facilities to VA facilities should be managed, the agencies cannot ensure that VA, IHS, and tribal facilities have a consistent understanding of the options available for referrals of AI/AN veterans to VA specialty care. This could result in an AI/AN veteran receiving, and the federal government paying for, duplicative tests if the veteran is reassessed by VA primary care before being referred to specialty care. GAO is making three recommendations—one each to VA and IHS to establish measurable targets for performance measures and one to VA to establish written guidance for referring AI/AN veterans to VA facilities for specialty care. VA and HHS concurred with these recommendations.