Actions VA and IHS Have Taken to Improve Access to Care for Native American Veterans Face Implementation Challenges, and Oversight and Accountability Are Lacking

VA and IHS staff have taken actions to improve access to care, including  strengthening outreach and enrollment efforts, expanding services  offered, increasing efforts to improve cultural competency, and  implementing reimbursement agreements. VA and IHS Have Taken Actions to Improve Access to Care, but Implementation Challenges Limit Their Effectiveness

In four main areas, VA and IHS have taken actions to improve access to  care for Native American veterans: (1) outreach and enrollment,   (2) expanded services including telehealth, (3) training and improvement  in cultural competency, and (4) reimbursement agreements. Although VA and IHS have undertaken a variety of outreach efforts,  officials from VA, IHS, and THP facilities identified two main ongoing  challenges to implementing effective outreach to Native American  veterans—the lack of available data to identify eligible Native American  veterans and insufficient agency resources to effectively conduct  outreach in rural areas. According to VA and IHS officials at another site  we visited, the local VA medical center and an IHS facility  collaborated to establish a VA primary care presence at the IHS  facility. First, oversight of the MOU’s implementation is inconsistent and, in 2013,  the officials tasked with this oversight did not meet and did not  systematically evaluate the progress of MOU implementation. Without consistent oversight, formal guidance on  responsibilities for MOU implementation, and the prioritization of MOU  implementation, leadership in VA and IHS do not have reasonable  assurance that the objectives of the MOU related to access to care are  being addressed. According to VA and IHS agency officials, the  only documentation outlining the procedures to report VA and IHS  progress in implementing the MOU is contained in a set of training slides  used in a December 2012 staff training session. However, VA and IHS officials said that these training slides are not  binding because they have not been formalized in written policy or  guidance, including establishing clearly defined roles and responsibilities. Prioritization of MOU Implementation Is Lacking

VA and IHS leaders have not made MOU implementation a priority, which  threatens the ability of the two agencies to move forward in implementing  the MOU as it relates to access to care. Moreover, key  members of the Joint Implementation Task Force attributed their lack of  tracking and oversight of the MOU activities in part to their perception that  other work-related responsibilities had a higher priority than some of their  MOU related responsibilities. Native American Veterans and Their Representatives Reported Mixed Views on Whether Access to Care Has Improved

Although the majority of Native American veterans and their  representatives we contacted reported that they thought access to care  for Native American veterans had improved over the past 3 years, a  number of others said either that they did not believe that access to care  had improved during that time or they did not know whether it had. Of the 102 representatives, 53 reported that in the last 3 years there  had been an increase in the number of Native American veterans  accessing health care at a VA, IHS, or THP facility. However, 12 felt  that there had been no change and 36 reported that they didn’t know. Conclusions

Native American veterans have historically faced many issues in  accessing health care and to their credit, both VA and IHS have taken  actions under the 2010 memorandum of understanding to improve access  to care for Native American veterans. Recommendation for Executive Action

To improve access to care for Native American veterans through MOU  implementation, we recommend that the Acting Secretary of Veterans  Affairs and the Secretary of Health and Human Services take the  following action:  Establish written policy or guidance designating specific roles and  responsibilities for agency staff to hold leadership accountable and  improve implementation and oversight of the MOU.
Why GAO Did This Study

Native Americans who have served in the military may be eligible for health care services from both VA and IHS, but according to reports some have had problems accessing care. In 2010 these two agencies expanded upon an MOU designed to improve Native American veterans' access to care at their facilities. GAO was asked to examine how the MOU has increased access to care.
This report examines: (1) the actions that VA and IHS have taken to implement the provisions in the 2010 MOU related to access to care for Native American veterans, and (2) what is known about how access to care for Native American veterans has improved. To conduct this work, GAO reviewed agency documents and VA and IHS reimbursement data and interviewed VA and IHS officials. GAO also visited three sites selected to reflect geographic variation to learn about access to care locally through interviews with regional VA and IHS officials, health facility officials, and Native American veterans and their tribal representatives. GAO also contacted other individuals who help Native American veterans seek enrollment in the VA to obtain their insights about improvements in access to care.

What GAO Found

The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) have taken a variety of actions to improve access to care for Native American veterans under their 2010 memorandum of understanding (MOU); however according to stakeholders, these agencies face substantial implementation challenges. VA and IHS have taken actions to (1) strengthen outreach and enrollment through information sharing and training; (2) expand services through national and local projects; (3) increase training about cultural competency for staff at VA and IHS facilities; and (4) establish reimbursement agreements that allow VA to reimburse IHS facilities for services provided to veterans. However, in each of these areas challenges remain, such as insufficient data to identify Native American veterans for outreach, obstacles to reaching those who live in very remote areas, and technological challenges such as lack of Internet connectivity or phone lines.
While VA and IHS have taken actions to increase access, the oversight, accountability, and prioritization of MOU implementation are lacking. Specifically:
Oversight is inconsistent: In 2013, the officials tasked with oversight of the implementation of the MOU did not meet and did not systematically evaluate the progress of MOU implementation.
Written policies and guidance are lacking: According to officials, the only documentation outlining the procedures to report VA and IHS progress on implementation efforts is contained in a set of training slides used in a December 2012 training session, and these slides have not been formalized in written policy or guidance.
Prioritization of MOU implementation is lacking: Leadership of VA and IHS have not made MOU implementation a priority, which threatens the ability of the two agencies to move forward in implementing the MOU. Key officials attributed this, in part, to their perception that their non-MOU related responsibilities had a higher priority.
Without consistent oversight, formal policy or guidance on responsibilities for MOU implementation, and the prioritization of MOU implementation, VA and IHS leadership do not have reasonable assurance that the objectives of the MOU related to access to care are being addressed.
Native American veterans and their representatives that GAO contacted reported mixed views on whether access to care has improved over the past 3 years. Although a majority reported that access to care had improved, others either said that that they did not think it had improved or were unsure. For example, 53 of 102 Native American veterans representatives GAO contacted reported that in the last 3 years there had been an increase in the number of Native American veterans accessing health care at VA or IHS-funded facilities; however, 12 felt there had been no change, and 36 said they did not know.

What GAO Recommends

GAO recommends that VA and IHS establish written policy or guidance designating specific roles and responsibilities for agency staff to hold leadership accountable and improve implementation and oversight of the MOU. VA and IHS agreed with GAO's recommendation.