	Background

VA and DOD have distinct missions and health care systems to provide  services to their respective beneficiaries. 1.) According to VA and DOD department-level officials, the departments do  not require that all collaboration sites develop and use performance  measures to assess the collaborations’ effectiveness and efficiency, in  particular to measure their progress in meeting the departments’ shared  goals of improved health care access, quality, and costs. In particular, VA officials told us they do  not want to overburden sites with performance measures and monitoring  requirements, which they said may discourage future collaborations. In the absence of a department-level requirement for performance  measures for all collaboration sites, some sites we reviewed have  developed their own performance measures. VA and DOD Face Several Significant Barriers That Hinder Collaboration, Despite Taking Some Actions to Address Those Barriers

VA and DOD face a number of significant barriers that hinder their  collaboration efforts. Without additional department-level actions to  address incompatible policies and practices, those barriers will continue  to hinder collaboration efforts and lead to inefficiencies at the local level. However, because VA and DOD collect, store, and process health  information in different IT systems, providing access to the information  needed to best treat those patients has proved problematic. 3.) At the department level, VA and DOD officials said VA and DOD have  taken some steps to address reimbursement issues, but that sites will still  need to find ways to bridge VA and DOD’s differences. In addition,  some DOD providers who treat patients at the Biloxi VA facility now  separately enter workload information into DOD’s IT system. Joint VA and DOD Planning for Construction of Medical Facilities

VA and DOD department-level officials reported that several barriers  hinder their efforts to jointly plan construction of medical facilities to serve  both departments’ beneficiaries, and sometimes lead to missed  opportunities to collaborate. VA and DOD Do Not Have a Fully Developed Process for Systematically Identifying New and Enhanced Collaboration Opportunities

VA and DOD do not have a fully developed process for systematically  identifying opportunities for new or enhanced collaboration that could  facilitate the departments’ shared goals of improving access, quality, and  costs. Instead, the identification of new or enhanced collaboration  opportunities is largely left to local medical facility leadership. Although  the departments do have a process for jointly identifying a select number  of sites where there are opportunities for new or expanded collaboration,  that process does not address all options for collaboration across both  health care systems, nor is there a requirement that the sites identified by  that process move forward with collaboration. Until VA and DOD fully  develop a joint process to systematically identify and pursue potential  collaboration opportunities, the departments may miss opportunities to  improve patients’ access to and quality of care, and to reduce costs, such  as by addressing overlap and duplication of services that may exist  between the two health care systems. In  particular, the departments have not taken sufficient actions to: develop  and use performance measures to assess the effectiveness and  efficiency of collaboration, overcome key barriers to collaboration, and  identify new or enhanced collaboration opportunities. Recommendations for Executive Action

To help assess progress, identify areas for improvement, and make  informed decisions about health care collaborations, we recommend that  the Secretaries of Veterans Affairs and Defense require collaboration  sites to develop and implement a process for using performance  measures to gauge their progress in achieving goals related to access,  quality of care, and costs. Specifically, we recommend that the Secretaries of Veterans Affairs and  Defense take the following three actions: expedite and communicate a plan with time frames for when iEHR  solutions will be made available to joint ventures and other  collaboration sites;  take steps to resolve problems with collaboration sites’ incompatible  business and administrative processes, including reimbursement for  services, collection of workload information, dual credentialing, and  computer security training; and  clarify, as part of the newly initiated joint efforts to address base  access, departmental guidance regarding collaboration to include a  discussion of base access issues that local officials should consider  when discussing and planning collaboration efforts; this could include  a discussion of successful approaches that current collaboration sites  have adopted to facilitate base access for veterans and their escorts.
Why GAO Did This Study

VA and DOD operate two of the nation's largest health care systems at estimated annual costs of about $53 billion and $49 billion, respectively, for fiscal year 2013, and have established collaboration sites to deliver care jointly with the aim of improving access, quality, and cost-effectiveness of care. In addition, collaborations could help reduce duplication and overlap between the two health care systems, potentially saving tax dollars and helping VA and DOD provide more efficient and effective services.
A committee report accompanying the Consolidated Appropriations Act, 2012, directed GAO to report on aspects of VA and DOD collaboration. This report examines the extent to which (1) VA and DOD assess effectiveness and efficiencies at collaboration sites; (2) barriers exist that affect collaboration; and (3) VA and DOD identify opportunities for collaboration. GAO conducted site visits to selected VA and DOD collaboration sites; reviewed VA and DOD documents such as sharing agreements; and interviewed VA and DOD officials.

What GAO Found

The Department of Veterans Affairs (VA) and Department of Defense (DOD) do not require that all collaboration sites--locations where the two departments share health care resources through hundreds of agreements and projects--develop and use performance measures to assess their effectiveness and efficiency. Officials cited several reasons for this, including not wanting to overburden sites with measures and monitoring requirements. Although VA and DOD require some limited performance information--such as the return on investment for pilot projects--without comprehensive performance measures, they lack information that could help decision makers assess collaboration sites' overall progress in meeting the departments' shared goals of improved health care access, quality, and costs; identify areas for improvement; and make informed decisions. Also, the departments cannot document the overall cost effectiveness of their collaboration efforts. In the absence of required measures for all sites, some have developed their own, but these fragmented efforts do not provide sufficient information about the overall results of collaborations.
The departments face a number of key barriers that hinder collaboration efforts. In particular, GAO identified incompatible policies and practices in four areas:
Information technology (IT) systems . Because VA and DOD collect, store, and process health information in different IT systems, providing access to information needed to best treat patients has proved problematic.
Business and administrative processes . Different billing practices, difficulties capturing patient workload information, and overlapping efforts in credentialing providers and computer security training reduce efficiency.
Access to military bases . Balancing base security needs with veterans' needs to access medical facilities on base creates some difficulties.
Medical facility construction . Misaligned construction planning processes hinder efforts to jointly plan facilities to serve both VA and DOD beneficiaries.
Although VA and DOD officials have taken some steps to address these areas, such as efforts to improve data sharing, without additional department-level actions, barriers will continue to hinder collaboration and lead to inefficiencies.
VA and DOD do not have a fully developed process for systematically identifying all opportunities for new or enhanced collaboration. Instead, the identification of those collaboration opportunities is largely left to local medical facility leadership. Although the departments have a process for jointly identifying a select number of sites with opportunities for new or expanded collaboration, that process does not address all opportunities for collaboration across both health care systems and there is no requirement that sites identified by that process move forward to implement collaboration. Without a fully developed process to systematically identify and select additional collaboration opportunities, the departments may miss opportunities to achieve their shared goals and reduce duplication of services, such as through additional sharing agreements.

What GAO Recommends

GAO recommends several actions, including that VA and DOD: require collaboration sites to develop performance measures related to access, quality, and costs; address barriers hindering collaboration; and develop a process to more systematically identify new or expanded collaboration opportunities. VA and DOD generally concurred with GAO's recommendations and noted steps they are taking to address them.