VA has a long history of partnering with DOD to enhance health care delivery to veterans, beginning in 1982 with the enactment of the Sharing Act, which aimed to promote more cost-effective use of health care resources through greater interagency sharing and coordination. Since that time, VA and DOD have participated in a wide array of sharing agreements for the mutual use or exchange of health care resources. Starting in the 1990s, VA and DOD expanded their sharing agreements to include joint ventures sharing agreements. Joint ventures are intended to avoid costs by maximizing available resources by jointly using a medical facility. According to VA, joint ventures involve a multi-entity, collaborative and strategic arrangement of at least 5 years in duration and a level of magnitude and scale comparable to VA’s current major capital threshold ($10 million). Joint ventures are complex in that they require an integrated approach because two separate health care systems must develop multiple sharing agreements that allow them to operate as one system at one location. VA currently has eight joint ventures with DOD (see fig. 1). For decades, VA has also developed and maintained partnerships, or affiliations, with university medical schools to provide health care to veterans. Through these affiliations, VA has been able to obtain medical services for veterans and provide training and education to medical residents. Although VA maintains numerous sharing agreements with its academic affiliates, it has not yet entered into a joint venture with any of them. However, in recent years, VA has had the opportunity to consider proposed joint ventures with several academic affiliates. In particular: University of Colorado Hospital (UCH): In the late 1990s, UCH proposed to integrate the VA Denver medical center and UCH into a new joint facility on the Fitzsimons campus, which is located in Aurora, Colorado. UCH and VA officials could not reach agreement on certain aspects of the proposal, and, therefore, discussions about a proposed joint venture between VA and UCH concluded in 2002. As required by law, in June 2007, VA issued a report that examined options for replacing its Denver facility, including the feasibility of entering into a partnership for constructing and operating a new facility with a federal, state, or local governmental agency or a suitable nonprofit organization. The report outlined three different options available to VA for replacing the facility and summarized their key advantages and disadvantages. Medical University of South Carolina: In 2002, MUSC proposed to partner with VA in the construction and operation of a new medical center in Charleston. Since that time, VA and MUSC have conducted several feasibility studies examining the potential collaboration. In 2006, Congress authorized the VA Secretary to enter into an agreement with MUSC to design and plan for the operation of a colocated joint-use medical facility. In November 2007, VA officials from the medical center in Charleston told us that VA and MUSC are still exploring a range of collaborative arrangements. Louisiana State University Health Care Services Division: In 2005, Hurricanes Katrina and Rita damaged VA’s New Orleans medical center and LSU medical facilities. In February 2006, VA and LSU signed a memorandum of understanding that established the framework for exploring whether any mutually beneficial sharing and contracting could occur between VA and LSU. In 2006, the VA Secretary was authorized to carry out the project as a collaborative effort with LSU. According to a VA official, no final decision on the proposed joint venture between VA and LSU has been made. However, VA has announced a preferred site for the joint facility in the downtown New Orleans area, adjacent to the site LSU has identified for its new facility (see fig. 2). Although no final decision has been made, the proximity of the preferred sites keeps the possibility of some type of joint facility as an option. Congress has had a long-standing interest in expanding VA’s and DOD’s sharing of health care resources. For example, the National Defense Authorization Act for Fiscal Year 2003 required VA and DOD to implement two programs—the joint incentive program and the demonstration program—to increase the sharing of health care resources between VA and DOD. The administration has also encouraged such collaboration between VA and DOD as a means to achieve more cost-effective use of health care resources. For example, in 2003, a presidential task force recommended that VA and DOD declare that joint ventures are integral to the standard operations of both departments and use the existing joint ventures as laboratories for developing future interdepartmental policy frameworks. Congress has also recently encouraged VA to explore opportunities for expanding its collaboration with academic affiliates as a potential cost-effective means of rebuilding and revitalizing VA’s aging infrastructure. Table 1 briefly describes selected laws and initiatives that have authorized and encouraged collaboration between VA and DOD as well as between VA and academic affiliates. VA and DOD have also taken steps to improve and expand their health care sharing activities. For example, since 2005, VA and DOD have convened annual conferences to highlight the progress and accomplishments of joint ventures as well as provided a forum for discussing common barriers to success, lessons learned, and best practices. In 2007, VA and DOD established the VA-DOD Joint Market Opportunities Working Group to examine the existing VA-DOD joint ventures and the potential for additional joint ventures. In the first phase of its review, the working group studied all eight existing VA-DOD joint ventures sites to identify best practices, lessons learned, and challenges. In the second phase of its review, the working group plans to assess potential opportunities for the colocation and comanagement of VA-DOD facilities. In addition, VA is exploring options to improve its partnerships with academic affiliates. For example, in 2006, VA established a blue ribbon panel to advise the VA Secretary on issues related to a comprehensive philosophical framework to enhance VA’s partnerships with medical schools and affiliated institutions. Among other things, the panel will explore the different types of health care partnerships between VA and academic affiliates, including joint ventures, in light of changes of medical education, research priorities, and the health care needs of veterans. The National Defense Authorization Act for Fiscal Year 2003 also required VA and DOD to develop and publish a joint strategic plan to shape, focus, and prioritize coordination and sharing efforts within the departments and to incorporate the goals and requirements of the joint strategic plan into each department’s strategic plan. In response, VA and DOD approved their initial Joint Strategic Plan in April 2003 to guide the departments’ health care resource-sharing activities. The plan is updated annually and included in the Joint Executive Council Annual Report to Congress. We have reported that there is no more important element in results- oriented management than an agency’s strategic planning effort. This effort is the starting point and foundation for defining what the department seeks to accomplish, identifying the strategies it will use to achieve the desired results, and then determining how well it succeeds in reaching goals and achieving objectives. We also previously reported that traditional management practices involve the creation of long-term strategic plans and regular assessments of progress toward achieving the plans’ stated goals. Moreover, the Government Performance and Results Act of 1993 requires agencies to set goals, measure performance, and report on their accomplishments. The use of performance measures is a key tool to help managers assess progress toward achieving the goals or objectives stated in their plans. This is also an important accountability tool to communicate a department’s progress to Congress and the public. Officials from VA and DOD and representatives from academic affiliates identified a number of potential benefits and concerns associated with joint ventures, but have not used performance measures to routinely or comprehensively document and assess the outcomes of the joint ventures. The most commonly cited potential benefits of joint ventures include improved access to care, cost savings and avoidances, and improved training opportunities. According to the officials we interviewed, joint ventures also raise a number of potential concerns, including potential conflicts between organizations’ missions and cultures, a potential loss of organizational identity and control, and uncertainties associated with staffing. While able to discuss these potential benefits and concerns, none of the officials involved in VA-DOD joint ventures use performance measures to routinely document or assess the outcomes of these endeavors at their facilities. Without this information, the extent to which identified benefits have been achieved and concerns mitigated at joint ventures is unknown. VA also does not use performance measures at the department level to determine what is being achieved through the joint ventures. As a result, VA has only limited and anecdotal information on the results of joint ventures. According to our interviews with officials from VA and DOD and representatives from academic affiliates, the potential benefits of joint ventures range from improved access to care to greater flexibility in the use of staff and other resources. Joint ventures provide improved access to care: VA and DOD officials said that the existing and proposed joint ventures provide their patients with improved access to specialty care and services that may not otherwise be available. For example, VA officials said that veterans in Honolulu have access to orthopedic care at the DOD medical center that would not otherwise be readily available. Similarly, according to LSU representatives, the proposed joint venture between VA and LSU would provide veterans with access to the only Level I Trauma Center in the region. Also, according to DOD officials in Fairfield, the joint venture with VA provides their beneficiaries with access to specialty care, such as neurosurgery, dialysis, and radiation oncology services. VA officials also said that joint ventures have resulted in fewer referrals of veterans to VA medical centers in other geographic areas, and, as a result, veterans do not have to travel great distances to receive care. For example, VA officials in El Paso said that local veterans, who previously had to travel over 250 miles to the Albuquerque VA medical center, can now be treated at the local DOD hospital. VA officials in Anchorage said that before a joint venture with DOD was established there, they referred most of their joint replacement cases to the Seattle VA medical center. With the joint venture, many veterans requiring joint replacement can now be treated at the facility in Anchorage and do not have to travel to Seattle.