VA Health Care
Additional Efforts to Better Assess Joint Ventures Needed
GAO-08-399, Mar 28, 2008
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The Department of Veterans Affairs (VA) and the Department of Defense (DOD) have a long history of partnering to achieve more cost-effective use of health care resources. Their partnerships have evolved to include joint ventures--joint efforts to construct or share medical facilities. VA has maintained eight joint ventures with DOD across the country. VA has also developed partnerships, or affiliations, with university medical schools to obtain health care services for veterans and provide training to medical residents. VA has not entered into a joint venture with an academic affiliate to date. However, several proposals for such joint ventures have surfaced in the last decade. This congressionally requested report discusses the (1) potential benefits and concerns associated with joint ventures and the extent to which they are documented and measured, (2) lessons learned from existing and proposed VA joint ventures, and (3) steps VA has taken to evaluate proposed joint ventures. To address these issues, GAO conducted site visits to and interviews with officials from all existing and proposed joint venture sites.
VA and DOD officials identified a number of potential benefits and concerns associated with joint ventures, but they have not routinely or comprehensively documented and measured them. Among the potential benefits, VA and DOD officials and academic affiliate representatives cited improved access to care, lower or avoided costs, and improved training opportunities. While the identified benefits are many, these officials and representatives also cited a number of concerns associated with joint ventures, such as potential conflicts of missions and cultures, a loss of organizational identity and control, staffing uncertainties, and financial risks. Although able to provide anecdotal information of the benefits and concerns associated with joint ventures, officials at the joint ventures do not use performance measures to routinely or comprehensively document and assess the outcomes of the joint ventures. Without such efforts, it is difficult to know to what extent these benefits and concerns have materialized. VA also does not use performance measures at the department level to determine what is being achieved through the joint ventures--thereby making it difficult to determine the overall outcomes of the joint ventures and to hold joint venture partners accountable for results. Officials from VA and DOD and representatives from academic affiliates identified several lessons they have learned from their experiences with the existing and proposed joint ventures. These lessons include the importance of establishing joint committees to work through issues, communicating frequently with their partners, securing leadership buy-in and support at all levels, developing contingency plans, allowing adequate time to implement change, and establishing clear roles and responsibilities. For example, at most VA-DOD joint venture sites, officials have created jointly staffed committees to tackle specific issues, such as clinical, financial, and information management. Also, in New Orleans, Louisiana, VA and its academic affiliate signed a memorandum of understanding that, among other things, identifies the roles and responsibilities of the parties involved in the proposed joint venture negotiations. VA has taken steps to enhance its process for evaluating proposed joint ventures, but additional efforts are warranted. In response to our previous recommendations, VA developed and issued criteria for evaluating joint venture proposals in November 2007. In addition, VA established working groups in Charleston, South Carolina, and New Orleans to examine joint venture proposals with academic affiliates. However, VA's criteria for evaluating joint venture proposals are not sufficiently specific, in terms of both the definition and the application of the criteria. As a result, VA's evaluations of joint venture proposals could be inconsistent and, therefore, may not serve as a reliable guide for federal investments in joint ventures. In addition, the criteria are not tailored to take into account differences in prospective joint venture partners to ensure that VA applies the appropriate level of review and scrutiny to proposals.
Status Legend:
Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
- In Process
- Open
- Closed - implemented
- Closed - not implemented
Recommendations for Executive Action
Recommendation: To develop a more comprehensive framework for evaluating existing and future joint ventures, the Secretary of Veterans Affairs should develop departmental performance measures to assess the outcomes of joint ventures and to determine the extent to which strategic goals are being achieved.
Agency Affected: Department of Veterans Affairs
Status: Open
Comments: VA and DoD have continued to collaboratively develop the FY08 Joint Incentive Fund project Enhanced DR (eDR) to provide a first-time, automated, referral and resource tracking capability which is bi-directional between the VA Pacific Islands Health Care System (VAPIHCS) and the Tripler Army Medical Center (TAMC) at Honolulu, HI. Enhanced DR completion at Honolulu is expected in FY10. In addition, a modification to the VA VistA-Fee legacy system is expected to be completed in FY11, which will capture workload and eliminate a major disincentive for VA/DOD sharing. The two projects will provide a business process prototype for VA/DoD Joint Ventures by FY11. Enhanced DR is expected to assist VA/DoD efforts to develop a more comprehensive framework for evaluating existing and future joint ventures. During FY11, the VA/DoD Health Executive Council (HEC) will evaluate Enhanced DR capability to enable the development of departmental performance measures to assess the outcomes of joint ventures and to determine the extent to which strategic goals are being achieved. If determined successful, DoD and VHA will submit a national level JIF proposal in response to the FY 2012 call for proposals. (Note: FY 2011 JIF proposals are due in July 2010, and the due date is subject to change).
Recommendation: To develop a more comprehensive framework for evaluating existing and future joint ventures, the Secretary of Veterans Affairs should revise the evaluation criteria for joint venture proposals to ensure they are measurable and specific--both in terms of definition and application.
Agency Affected: Department of Veterans Affairs
Status: Open
Comments: VA and DoD have continued to collaboratively develop the FY08 Joint Incentive Fund project Enhanced DR (eDR) to provide a first-time, automated, referral and resource tracking capability which is bi-directional between the VA Pacific Islands Health Care System (VAPIHCS) and the Tripler Army Medical Center (TAMC) at Honolulu, HI. Enhanced DR completion at Honolulu is expected in FY10. In addition, a modification to the VA VistA-Fee legacy system is expected to be completed in FY11, which will capture workload and eliminate a major disincentive for VA/DOD sharing. The two projects will provide a business process prototype for VA/DoD Joint Ventures by FY11. Enhanced DR is expected to assist VA/DoD efforts to develop a more comprehensive framework for evaluating existing and future joint ventures. During FY11, the VA/DoD Health Executive Council (HEC) will evaluate Enhanced DR capability to enable the development of departmental performance measures to assess the outcomes of joint ventures and to determine the extent to which strategic goals are being achieved. If determined successful, DoD and VHA will submit a national level JIF proposal in response to the FY 2012 call for proposals. (Note: FY 2011 JIF proposals are due in July 2010, and the due date is subject to change).
Recommendation: To develop a more comprehensive framework for evaluating existing and future joint ventures, the Secretary of Veterans Affairs should analyze the differences among types of joint venture partners to determine whether the evaluation criteria should be tailored to the type of partner (e.g., DOD or academic affiliate) and, if so, tailor the criteria accordingly.
Agency Affected: Department of Veterans Affairs
Status: Open
Comments: VA and DoD have continued to collaboratively develop the FY08 Joint Incentive Fund project Enhanced DR (eDR) to provide a first-time, automated, referral and resource tracking capability which is bi-directional between the VA Pacific Islands Health Care System (VAPIHCS) and the Tripler Army Medical Center (TAMC) at Honolulu, HI. Enhanced DR completion at Honolulu is expected in FY10. In addition, a modification to the VA VistA-Fee legacy system is expected to be completed in FY11, which will capture workload and eliminate a major disincentive for VA/DOD sharing. The two projects will provide a business process prototype for VA/DoD Joint Ventures by FY11. Enhanced DR is expected to assist VA/DoD efforts to develop a more comprehensive framework for evaluating existing and future joint ventures. During FY11, the VA/DoD Health Executive Council (HEC) will evaluate Enhanced DR capability to enable the development of departmental performance measures to assess the outcomes of joint ventures and to determine the extent to which strategic goals are being achieved. If determined successful, DoD and VHA will submit a national level JIF proposal in response to the FY 2012 call for proposals. (Note: FY 2011 JIF proposals are due in July 2010, and the due date is subject to change).