VA and DOD Health Care: Resource Sharing At Selected Sites
(21-JUL-04, GAO-04-792).
Congress has long encouraged the Department of Veterans Affairs
(VA) and the Department of Defense (DOD) to share health
resources to promote cost-effective use of health resources and
efficient delivery of care. In February 2002, the House Committee
on Veterans' Affairs described VA and DOD health care resource
sharing activities at nine locations. GAO was asked to describe
the health resource sharing activities that are occurring at
these sites. GAO also examined seven other sites that actively
participate in sharing activities. Specifically, GAO is reporting
on (1) the types of benefits that have been realized from health
resource sharing activities and (2) VA- and DOD-identified
obstacles that impede health resource sharing. GAO analyzed
agency documents and interviewed officials at DOD and VA to
obtain information on the benefits achieved through sharing
activities. The nine sites reviewed by the Committee and
reexamined by GAO are: 1) Los Angeles, CA; 2) San Diego, CA; 3)
North Chicago, IL; 4) Albuquerque, NM; 5) Las Vegas, NV; 6)
Fayetteville, NC; 7) Charleston, SC; 8) El Paso, TX; and 9) San
Antonio, TX. The seven additional sites GAO examined are: 1)
Anchorage, AK; 2) Fairfield, CA; 3) Key West, FL; 4) Pensacola,
FL; 5) Honolulu, HI; 6) Louisville, KY; and 7) Puget Sound, WA.
In commenting on a draft of this report, the departments
generally agreed with our findings.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-04-792
ACCNO: A11029
TITLE: VA and DOD Health Care: Resource Sharing At Selected
Sites
DATE: 07/21/2004
SUBJECT: Cost sharing (finance)
Health care facilities
Health care personnel
Health care services
Health resources utilization
Interagency relations
Health care costs
Health care cost control
Medical information systems
Cost effectiveness analysis
Systems compatibility
******************************************************************
** This file contains an ASCII representation of the text of a **
** GAO Product. **
** **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced. Tables are included, but **
** may not resemble those in the printed version. **
** **
** Please see the PDF (Portable Document Format) file, when **
** available, for a complete electronic file of the printed **
** document's contents. **
** **
******************************************************************
GAO-04-792
United States Government Accountability Office
GAO Report to the Chairman, Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs, House of Representatives
July 2004
VA AND DOD HEALTH CARE
Resource Sharing at Selected Sites
GAO-04-792
Highlights of GAO-04-792, a report to the Chairman, Subcommittee on
Oversight and Investigations, Committee on Veterans' Affairs, House of
Representatives
Congress has long encouraged the Department of Veterans Affairs (VA) and
the Department of Defense (DOD) to share health resources to promote
cost-effective use of health resources and efficient delivery of care. In
February 2002, the House Committee on Veterans' Affairs described VA and
DOD health care resource sharing activities at nine locations. GAO was
asked to describe the health resource sharing activities that are
occurring at these sites. GAO also examined seven other sites that
actively participate in sharing activities. Specifically, GAO is reporting
on (1) the types of benefits that have been realized from health resource
sharing activities and (2) VA-and DOD-identified obstacles that impede
health resource sharing.
GAO analyzed agency documents and interviewed officials at DOD and VA to
obtain information on the benefits achieved through sharing activities.
The nine sites reviewed by the Committee and reexamined by GAO are: 1) Los
Angeles, CA; 2) San Diego, CA; 3) North Chicago, IL; 4) Albuquerque, NM;
5) Las Vegas, NV; 6) Fayetteville, NC; 7) Charleston, SC;
8) El Paso, TX; and 9) San Antonio, TX. The seven additional sites GAO
examined are: 1) Anchorage, AK; 2) Fairfield, CA; 3) Key West, FL; 4)
Pensacola, FL; 5) Honolulu, HI; 6) Louisville, KY; and 7) Puget Sound, WA.
In commenting on a draft of this report, the departments generally agreed
with our findings.
July 2004
VA AND DOD HEALTH CARE
Resource Sharing at Selected Sites
At the 16 sites GAO reviewed, VA and DOD are realizing benefits from
sharing activities, specifically better facility utilization, greater
access to care, and reduced federal costs. While all 16 sites are engaged
in health resource sharing activities, some sites share significantly more
resources than others. For example, at one site VA was able to utilize
Navy facilities to provide additional sources of care and reduce its
reliance on civilian providers, thus lowering its purchased care cost by
about $385,000 annually. Also, because of the sharing activity taking
place at this site, VA has modified its plans to build a new $100 million
hospital and instead plans to build a clinic that will cost about $45
million. However, at another site the sharing activity was limited to the
use of a nurse practitioner to assist with primary care and the sharing of
a psychiatrist and a psychologist.
GAO found that the primary obstacle cited by almost all of the agency
officials interviewed was the inability of VA and DOD computer systems to
communicate and exchange patient health information between departments.
VA and DOD medical facilities involved in treating both agencies' patient
populations must expend staff resources to enter information on the health
care provided into the patient records in both systems. Local VA officials
also expressed a concern that security screening procedures have increased
the time it takes for VA beneficiaries and their families to gain entry to
facilities located on Air Force, Army, and Navy installations during
periods of heightened security.
www.gao.gov/cgi-bin/getrpt?GAO-04-792.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia A. Bascetta at (202)
512-7101.
Contents
Letter
Results in Brief
Background
Resource Sharing Activities Result in Better Access and Reduced
Costs
VA and DOD Identified Two Obstacles that Impede Resource
Sharing
Agency Comments and Our Evaluation
1
2 3
4
6 9
Appendix I Scope and Methodology
Appendix II
Resource Sharing at 16 Sites
Anchorage, Alaska
Fairfield, California
Los Angeles, California
San Diego, California
Key West, Florida
Pensacola, Florida
Honolulu, Hawaii
North Chicago, Illinois
Louisville, Kentucky
Las Vegas, Nevada
Albuquerque, New Mexico
Fayetteville, North Carolina
Charleston, South Carolina
El Paso, Texas
San Antonio, Texas
Puget Sound, Washington
13
13 13 14 14 15 15 16 16 17 18 19 19 19 20 20 21
Appendix III
Comments from the Department of Veterans Affairs and the Department of
Defense 22
Related GAO Products 27
Abbreviations
CMAC Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS) Maximum Allowable Charge CMOP Consolidated Mail
Outpatient Pharmacy DOD Department of Defense ICU Intensive Care Unit MRI
magnetic resonance imaging MTF military treatment facility VA Department
of Veterans Affairs VHA Veterans Health Administration VAMC VA medical
center
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.
United States Government Accountability Office Washington, DC 20548
July 21, 2004
The Honorable Steve Buyer
Chairman
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
House of Representatives
Dear Mr. Chairman:
In 1982, Congress passed the Veterans' Administration and Department of
Defense Health Resources Sharing and Emergency Operations Act
(Sharing Act) to promote cost-effective use of health care resources and
efficient delivery of care.1 Specifically, Congress authorized the
Department of Veterans Affairs (VA)2 medical centers and the Department
of Defense (DOD) military treatment facilities to enter into sharing
agreements with each other to buy, sell, and barter medical and support
services. Following the Sharing Act, Congress passed legislation to
encourage and foster sharing of resources between VA and DOD-
including start-up funds for sharing projects, expanded legal authority to
enter into agreements, and funding for demonstration projects.3 You have
an interest in the benefits that result from sharing activities and the
obstacles that impede sharing. At your request, this report provides
information on (1) the types of benefits that have been realized from
health resource sharing activities and (2) VA- and DOD-identified
obstacles that impede health resource sharing.
This report describes the benefits that are being realized at 16 VA and
DOD sites that are engaged in health resource sharing activities. Nine of
the sites4 were the focus of a February 2002 House Committee on
1Pub. L. No. 97-174, 96 Stat. 70.
2The Department of Veterans Affairs was established on March 15, 1989,
succeeding the Veterans Administration.
3Bob Stump National Defense Authorization Act for Fiscal Year 2003, Pub.
L. No. 107-314, Sections 721, 722, 116 Stat. 2589-98 (2002).
4The nine sites in the report were: Los Angeles, California; San Diego,
California; North Chicago, Illinois; Fayetteville, North Carolina;
Albuquerque, New Mexico; Las Vegas, Nevada; Charleston, South Carolina; El
Paso, Texas; and San Antonio, Texas.
Veterans' Affairs report5 that described health resource sharing
activities between VA and DOD. We selected seven other sites that actively
participated in sharing activities6 to ensure representation from each
service at locations throughout the nation. We analyzed agency documents
and interviewed officials at VA and DOD, including headquarters staff and
field office staff who manage sharing activities at the 16 sites. We made
field visits to six of them. We obtained documentation on improvements or
enhancements to the delivery of health care to beneficiaries, and on cost
reductions. Ten sites provided information on estimated cost reductions.
We reviewed the supporting documentation and obtained clarifying
information from agency officials. We also obtained documentation and the
opinions of agency officials on the obstacles that exist either internally
(within their own agency) or externally (with their sharing partner) to
resource sharing activities. We obtained and reviewed VA and DOD policies
and regulations governing sharing agreements and reviewed relevant reports
from the DOD Inspector General, DOD contractors, and our prior work. Our
work was performed from June 2003 through June 2004 in accordance with
generally accepted government auditing standards. For more details on our
scope and methodology, see appendix I.
VA and DOD are realizing benefits from sharing activities, specifically,
better facility utilization, greater access to care, and reduced federal
costs at the 16 sites we reviewed. While all 16 sites are engaged in
health resource sharing activities, some sites share significantly more
resources than others. For example, at one site VA was able to utilize
Navy facilities to provide additional sources of care and reduce its
reliance on civilian providers, thus lowering its purchased care cost by
about $385,000 annually. Also, because of the sharing activity taking
place at this site, VA has modified its plans to build a new $100 million
hospital and instead plans to build a clinic that will cost about $45
million. However, at another site the sharing activity was limited to the
use of a nurse practitioner to assist with primary care and the sharing of
a psychiatrist and a psychologist.
5Department of Veterans Affairs and Department of Defense Health Resources
Sharing: Staff Report to the Committee on Veterans' Affairs, U.S. House of
Representatives 107th Congress, February 25, 2002, Washington, D.C.
6The seven sharing sites are Anchorage, Alaska; Fairfield, California; Key
West, Florida; Pensacola, Florida; Honolulu, Hawaii; Louisville, Kentucky;
and Puget Sound, Washington.
Results in Brief
The primary obstacle cited by almost all of the officials we interviewed
from both agencies was the inability of VA and DOD computer systems to
communicate and exchange patient health information between departments.
Hence, VA and DOD medical facilities involved in treating both agencies'
patient populations must expend staff resources to enter health care
information into both systems. Local VA officials also expressed a concern
that security screening procedures have increased the time it takes for VA
beneficiaries and their families to gain entry to facilities located on
Air Force, Army, and Navy installations during periods of heightened
security.
VA and DOD commented on a draft of this report and generally agreed with
our findings.
Background
VA operates one of the nation's largest health care systems, spending
about $26.5 billion a year to provide care to approximately 5.2 million
veterans who receive health care through 158 VA medical centers (VAMC) and
almost 900 outpatient clinics nationwide. DOD spends about $26.7 billion
on health care for over 8.9 million beneficiaries, including active duty
personnel and retirees, and their dependents. Most DOD health care is
provided at more than 530 Army, Navy, and Air Force military treatment
facilities (MTF) worldwide, supplemented by civilian providers.
To encourage sharing of federal health resources between VA and DOD, in
1982, Congress passed the Sharing Act. Previously, VA and DOD health care
facilities, many of which are collocated or in close geographic proximity,
operated virtually independent of each other. The Sharing Act authorizes
VAMCs and MTFs to become partners and enter into sharing agreements to
buy, sell, and barter medical and support services. The head of each VA
and DOD medical facility can enter into local sharing agreements. However,
VA and DOD headquarters officials review and approve agreements that
involve national commitments such as joint purchasing of pharmaceuticals.
Agreements can be valid for up to 5 years. The intent of the law was not
only to remove legal barriers, but also to encourage VA and DOD to engage
in health resource sharing to more effectively and efficiently use federal
health resources.
VA and DOD sharing activities fall into three categories:
o Local sharing agreements allow VA and DOD to take advantage of their
capacities to provide health care by being a provider of health services,
a receiver of health services, or both. Health services shared under these
agreements can include inpatient and outpatient care; ancillary services,
such as diagnostic and therapeutic radiology; dental care; and specialty
care services such as service for the treatment of spinal cord injury.
Other services shared under these agreements include support services such
as administration and management, research, education and training,
patient transportation, and laundry. The goals of local sharing agreements
are to allow VAMCs and MTFs to exchange health services in order to
maximize their use of resources and provide beneficiaries with greater
access to care.
o Joint venture sharing agreements, as distinguished from local sharing
agreements, aim to avoid costs by pooling resources to build a new
facility or jointly use an existing facility. Joint ventures require more
cooperation and flexibility than local agreements because two separate
health care systems must develop multiple sharing agreements that allow
them to operate as one system at one location.
o National sharing initiatives are designed to achieve greater
efficiencies,
Resource Sharing Activities Result in Better Access and Reduced Costs
that is, lower cost and better access to goods and services when they are
acquired on a national level rather than by individual facilities-for
example, VA and DOD's efforts to jointly purchase pharmaceuticals for
nationwide distribution.
VA and DOD are realizing benefits from sharing activities, specifically
greater access to care, reduced federal costs, and better facility
utilization at the 16 sites we reviewed. While all 16 sites were engaged
in health resource sharing activities, some sites share significantly more
resources than others.
In 1994 VA and DOD opened a joint venture hospital in Las Vegas, Nevada,
to provide services to VA and DOD beneficiaries. The joint venture
improved access for VA beneficiaries by providing an alternative source
for care other than traveling to VA facilities in Southern California. It
also improved access to specialized providers for DOD beneficiaries.
Examples of the types of services provided include vascular surgery,
plastic surgery, cardiology, pulmonary, psychiatry, ophthalmology,
urology, computed tomography scan, magnetic resonance imaging (MRI);
nuclear medicine, emergency medicine and emergency room, and respiratory
therapy.7 The site is currently in the process of enlarging the emergency
room.
7On May 7, 2004, the Secretary of Veterans Affairs announced that a new VA
medical center would be opened in Las Vegas, NV. According to the
Secretary, VA will continue its sharing activities with DOD in Las Vegas,
NV.
In Pensacola, Florida, under a sharing agreement entered into in 2000, VA
buys most of its inpatient services from Naval Hospital Pensacola. Through
this agreement VA is able to utilize Navy facilities and reduce its
reliance on civilian providers, thus lowering its purchased care cost by
about $385,000 annually. Further, according to a VA official, the
agreement has allowed VA to modify its plans to build a new hospital and
instead build a clinic at significantly reduced cost to meet increasing
veteran demand for health care services. Using VA's cost per square foot
estimates for hospital and clinic construction, the agency estimates that
it will cost $45 million8 to build a new clinic compared to $100 million
for a hospital.
In Louisville, Kentucky, since 1996, VA and the Army have been engaged in
sharing activities to provide services to beneficiaries that include
primary care, audiology, radiology, podiatry, urology, internal medicine,
and ophthalmology. For fiscal year 2003, a local VA official estimated
that VA reduced its cost by $1.7 million as compared to acquiring the same
services in the private sector through its agreements with the Army; he
also estimated that the Army reduced its cost by about $1.25 million as
compared to acquiring the same services in the private sector. As an
example of the site's efforts to improve access to care and reduce costs,
in 2003 VA and DOD jointly leased a MRI unit. The unit reduces the need
for VA and DOD beneficiaries to travel to more distant sources of care. A
Louisville VA official stated that the purchase reduced the cost by 20
percent as compared to acquiring the same services in the private sector.
In San Antonio, Texas, VA and the Air Force share a blood bank. Under a
1991 sharing agreement, VA provides the staff to operate the blood bank
and the Air Force provides the space and equipment. According to VA, the
blood bank agreement saves VA and DOD about $400,000 per year. Further, VA
entered into a laundry service agreement with Brooke Army Medical Center
in 2002 to utilize some of VA's excess laundry capacity. Under the
contract VA processes 1.7 million pounds of laundry each year for the Army
at an annual cost of $875,000.
Sites such as Las Vegas, Nevada; Pensacola, Florida; Louisville, Kentucky;
and San Antonio, Texas shared significant resources compared to sites at
8Authorization for the construction of the clinic was given in Pub. L. No.
108-170, Section 211, 117 Stat. 2042, 2048. The statute provides that
funding for the construction must come either from funds appropriated for
2004, or funds appropriated before 2004 for construction and major
projects that are still available. Pub. L. No. 108-170, S:214, 117 Stat.
2049.
VA and DOD Identified Two Obstacles that Impede Resource Sharing
Los Angeles, California and Charleston, South Carolina. For example, the
sharing agreement at Los Angeles provided for the use of a nurse
practitioner to assist with primary care and the sharing of a psychiatrist
and a psychologist. See appendix II for the VA and DOD partners at each of
the 16 sites and examples of the sharing activities taking place.
The primary obstacle cited by officials at 14 of 16 sites we interviewed
was the inability of computer systems to communicate and share patient
health information between departments. Furthermore, local VA and DOD
officials involved with sharing activities raised a concern that security
check-in procedures implemented since September 11, 2001, have increased
the time it takes to gain entry to medical facilities located on military
installations during periods of heightened security.
VA and DOD Computer Systems Cannot Share Patient Record Information
VA's and DOD's patient record systems cannot share patient health
information electronically. The inability of VA's and DOD's patient record
systems to quickly and readily share information on the health care
provided at medical facilities is a significant obstacle to sharing
activities. One critical challenge to successfully sharing information
will be to standardize the data elements of each department's health
records. While standards for laboratory results were adopted in 2003, VA
and DOD face a significant undertaking to standardize the remaining health
data. According to the joint strategy that VA and DOD have developed, VA
will have to migrate over 150 variations of clinical and demographic data
to one standard, and DOD will have to migrate over 100 variations of
clinical data to one standard.
The inability of VA and DOD computer systems to share information forces
the medical facilities involved in treating both agencies' patient
populations to expend staff resources to maintain patient records in both
systems. For example, at Travis Air Force Base, both patient records
systems have been loaded on to a single workstation in each department, so
that nurses and physicians can enter patient encounter data into both
systems. However, the user must access and enter data into each system
separately. In addition to VA and DOD officials' concerns about the added
costs in terms of staff time, this method of sharing medical information
raises the potential for errors-including double entry and transcription-
possibly compromising medical data integrity.9
VA and DOD have been working since 1998 to modify their computer systems
to ensure that patient health information can be shared between the two
departments. In May 2004, we reported that they have accomplished a
one-way transfer of limited health data from DOD to VA for separated
service members.10 Through the transfer, health care data for separated
service members are available to all VA medical facilities. This transfer
gives VA clinicians the ability to access and display health care data
through VA's computerized patient record system remote data views11 about
6 weeks after the service member's separation. The health care data
include laboratory, pharmacy, and radiology records, and are available for
approximately 1.8 million personnel who separated from the military
between 1987 and June 2003. A second phase of the one-way transfer,
completed in September 2003, added to the base of health information
available to VA clinicians by including discharge summaries,12 allergy
information, admissions information, and consultation results.13
VA and DOD are developing a two-way transfer of health information for
patients who obtain care from both systems. Patients involved include
those who receive care and maintain health records at multiple VA or DOD
medical facilities within and outside the United States. Upon viewing the
medical record, a VA clinician would be provided access to clinical
information on the patient residing in DOD's computerized health record
systems. In the same manner, when a veteran seeks medical care at an MTF,
the attending DOD clinician would be provided access to the veteran's
health information existing in VA's computerized health record systems.
9See U.S. General Accounting Office, VA and Defense Health Care: Increased
Risk of Medication Errors for Shared Patients, GAO-02-1017 (Washington,
D.C.: Sept. 27, 2002).
10See U.S. General Accounting Office, Computer-Based Patient Records:
Improved Planning and Project Management Are Critical to Achieving Two-Way
VA-DOD Health Data Exchange, GAO-04-811T (Washington, D.C.: May 19, 2004).
11VA's remote data views allow authorized users to access patient health
care data from any VA medical facility.
12Discharge summaries include inpatient histories, diagnoses, and
procedures.
13See U.S. General Accounting Office, Computer-Based Patient Records:
Short-Term Progress Made, but Much Work Remains to Achieve a Two-Way Data
Exchange Between VA and DOD Health Systems, GAO-04-271T (Washington, D.C.:
Nov. 19, 2003).
In May 2004, we reported that VA's and DOD's approach to achieving the
two-way transfer of health information lacks a solid foundation and that
the departments have made little progress toward defining how they intend
to accomplish it.14 In March 2004 and June 2004,15 we also reported that
VA and DOD have not fully established a project management structure to
ensure the necessary day-to-day guidance of and accountability for the
undertaking, adding to the challenge and uncertainties of developing
two-way information exchange. Further, we reported that the departments
were operating without a project management plan that describes their
specific development, testing, and deployment responsibilities. These
issues cause us to question whether the departments will meet their 2005
target date for two-way patient health information exchange.
Security Procedures Increase Time to Gain Access to MTFs During Periods of
Heightened Security
During times of heightened security since September 11, 2001, according to
VA and DOD officials, screening procedures have slowed entry for VA
beneficiaries, and particularly for family members who accompany them, to
facilities located on Air Force, Army, and Navy installations. For
example, instead of driving onto Nellis Air Force Base in Las Vegas and
parking at the medical facility, veterans seeking treatment there must
park outside the base perimeter, undergo a security screening, and wait
for shuttle services to take them to the hospital for care.
Although sharing occurs in North Carolina between the Fayetteville VA
Medical Center and the Womack Army Medical Center, Ft. Bragg, the VA
hospital administrator expressed concerns regarding any future plans to
build a joint VA and DOD clinic at Ft. Bragg due to security precautions-
identity checks and automobile searches-that VA beneficiaries encounter
when attempting to access care. Consequently, the administrator prefers
that any new clinics be located on VA property for ease of access for all
beneficiaries.
14See GAO-04-811T.
15See U.S. General Accounting Office, Computer-Based Patient Records:
Sound Planning and Project Management Are Needed to Achieve a Two-Way
Exchange of VA and DOD Health Data, GAO-04-402T (Washington, D.C.: Mar.
17, 2004) and U.S. General Accounting Office, Computer-Based Patient
Records: VA and DOD Efforts to Exchange Health Data Could Benefit from
Improved Planning and Project Management, GAO-04-687 (Washington, D.C. :
June 7, 2004).
Agency Comments
and Our Evaluation
VA provided an example of how it and DOD are working to help resolve these
problems. In Pensacola, Florida, VA is building a joint ambulatory care
clinic on Navy property through a land-use arrangement. According to VA,
veterans' access to the clinic will be made easier. A security fence will
be built around the building site on shared VA and Navy boundaries and a
separate entrance and access road to a public highway will allow direct
entry. Special security arrangements will be necessary only for those
veterans who are referred for services at the Navy medical treatment
facility. Veterans who come to the clinic for routine care will experience
the same security measures as at any other VA clinic or medical center. VA
believes this arrangement gives it optimal operational control and
facilitates veterans' access while addressing DOD security concerns.
We requested comments on a draft of this report from VA and DOD. Both
agencies provided written comments that are found in appendix III. VA and
DOD generally agreed with our findings. They also provided technical
comments that we incorporated where appropriate.
In commenting on this draft, VA stated that VA and DOD are developing an
electronic interface that will support a bidirectional sharing of health
data. This approach is set forth in the Joint VA/DOD Electronic Health
Records Plan. According to VA, the plan provides for a documented strategy
for the departments to achieve interoperable health systems in 2005. It
included the development of a health information infrastructure and
architecture, supported by common data, communications, security, software
standards, and high-performance health information. VA believes these
actions will achieve the two-way transfer of health information and
communication between VA's and DOD's information systems.
In their comments, DOD acknowledged the importance of VA and DOD
developing computer systems that can share patient record information
electronically. According to DOD, VA and DOD are taking steps to improve
the electronic exchange of information. For example, VA and DOD have
implemented a joint project management structure for information
management and information technology initiatives-which includes a single
Program Manager and a single Deputy Program Manager with joint
accountability and day-to-day responsibility for project implementation.
Further, VA and DOD continue to play key roles as lead partners to
establish federal health information interoperability standards as the
basis for electronic health data transfer.
We recognize that VA and DOD are taking actions to implement the Joint
VA/DOD Electronic Health Records Plan and the joint project management
structure, and that they face significant challenges to do so.
Accomplishing these tasks is a critical step for the departments to
achieve interoperable health systems by the end of 2005.
DOD also agreed with the GAO findings on issues relating to veterans
access to military treatment facilities located on Air Force, Army, and
Navy installations during periods of heightened security. DOD stated that
they are working diligently to solve these problems, but are unlikely to
achieve an early resolution. They also stated that as VA and DOD plan for
the future, they will consider this issue during the development of future
sharing agreements and joint ventures.
We are sending copies of this report to the Secretary of Veterans Affairs,
the Secretary of Defense, interested congressional committees, and other
interested parties. We will also make copies available to others upon
request. In addition, this report is available at no charge on GAO's Web
site
at http://www.gao.gov. If you or your staff have any questions about this
report, please call me at (202) 512-7101 or Michael T. Blair, Jr., at
(404)
679-1944. Aditi Shah Archer and Michael Tropauer contributed to this
report.
Sincerely yours,
Cynthia A. Bascetta
Director, Health Care-Veterans'
Health and Benefits Issues
Appendix I: Scope and Methodology
This report describes the benefits that are being realized at 16
Department of Veterans Affairs (VA) and Department of Defense (DOD) sites
that are engaged in health resource sharing activities. Nine of the sites1
were the focus of a February 2002 House Committee on Veterans' Affairs
report2 that described health resource sharing activities between VA and
DOD. We selected seven other sites that actively participated in sharing
activities3 to ensure representation from each service at locations
throughout the nation. To obtain information on the resources that are
being shared we analyzed agency documents and interviewed officials at VA
and DOD headquarters offices and at VA and DOD field offices who manage
sharing activities at the 16 sites.
To gain information on the benefits of sharing and the problems that
impede sharing at selected VA and DOD sites, we asked VA and DOD personnel
at 16 sites to provide us with information on:
o shared services provided to beneficiaries including improvements or
enhancements to delivery of health care to beneficiaries,
o reduction in costs,
o and their opinions on barriers or obstacles that exist either
internally (within their own agency) or externally (with their partner
service or agency).
Ten sites provided information on estimated cost reductions. We reviewed
the supporting documentation and obtained clarifying information from
agency officials. Based on our review of the documentation and subsequent
discussions with agency officials we accepted the estimates as reasonable.
From the 16 sites, we judgmentally selected the following 6 sites to
visit: 1) Fairfield, California; 2) Pensacola, Florida; 3) Louisville,
Kentucky; 4) Fayetteville, North Carolina; 5) Las Vegas, Nevada; and 6)
Charleston, South Carolina. At the sites we visited, we interviewed local
VA and DOD
1The nine sites in the report were: Los Angeles, California; San Diego,
California; North Chicago, Illinois; Fayetteville, North Carolina;
Albuquerque, New Mexico; Las Vegas, Nevada; Charleston, South Carolina; El
Paso, Texas; and San Antonio, Texas.
2Department of Veterans Affairs and Department of Defense Health Resources
Sharing: Staff Report to the Committee on Veterans' Affairs, U.S. House of
Representatives 107th Congress, (Washington, D.C .: Feb. 25, 2002).
3The seven sharing sites are Anchorage, Alaska; Fairfield, California; Key
West, Florida; Pensacola, Florida; Honolulu, Hawaii; Louisville, Kentucky;
and Puget Sound, Washington.
Appendix I: Scope and Methodology
officials to obtain their views on resource-sharing activities and
obtained documents from them on the types of services that were being
shared. The sites were selected based on the following criteria: 1)
representation from each military service; 2) geographic location; and 3)
type of sharing agreement-local sharing agreement, joint venture, or
participant in a national sharing initiative.
We conducted telephone interviews with agency officials at the 10 sites
that we did not visit and requested supporting documentation from them to
gain an understanding of the sharing activities underway at each site.
We obtained and reviewed VA and DOD policies and regulations governing
sharing agreements and reviewed our prior work4 and relevant reports
issued by the DOD Inspector General and DOD contractors. Our work was
performed from June 2003 through June 2004 in accordance with generally
accepted government auditing standards.
4See Related GAO Products.
Appendix II: Resource Sharing at 16 Sites
Anchorage, Alaska
Fairfield, California
Partners: Alaska VA Healthcare System and 3rd Medical Group, Elmendorf Air
Force Base
The Department of Veterans Affairs (VA) and the Air Force have had a
resource-sharing arrangement since 1992. Building upon that arrangement,
in 1999, VA and the Air Force entered into a joint venture hospital.
According to VA and Air Force officials, they have been able to
efficiently and effectively provide services to both VA and the Department
of Defense (DOD) beneficiaries in the Anchorage area that would not have
been otherwise possible. The services to VA and DOD beneficiaries include
emergency room, outpatient, and inpatient care. Other services the Air
Force provides VA includes diagnostic radiology, clinical and anatomical
pathology, nuclear medicine, and MRI. VA contributes approximately 60
staff toward the joint venture. VA staff are primarily responsible for
operating the 10-bed intensive care unit (ICU). For fiscal year 2002, a
DOD official estimated that the Air Force avoids costs of about $6.6
million by utilizing the ICU as compared to acquiring the same services in
the private sector. Other VA staffing in the hospital lends support to the
emergency department, medical and surgical unit, social work services,
supply processing and distribution, and administration.
Partners: VA Northern California Health Care System and 60th Medical
Group, Travis Air Force Base
In 1994, VA and the Air Force entered into a joint venture at Travis Air
Force Base. Under this joint venture, VA contracts for inpatient care,
radiation therapy, and other specialty, ancillary, and after-hours
teleradiology services it need from the Air Force. In return, the Air
Force contracts for ancillary and pharmacy support from VA. The most
recent expansion of the joint venture in 2001 included activation of a VA
clinic located adjacent to the Air Force hospital-this clinic includes a
joint neurosurgery clinic.
Each entity currently reimburses the other at 75 percent of the Civilian
Health and Medical Program of the Uniformed Services (CHAMPUS) Maximum
Allowable Charge (CMAC)1 rate. In March 2004, a VA official
1To reimburse civilian physicians, DOD has established a fee schedule-the
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
maximum allowable charge (CMAC) rates-which is the highest amount DOD will
pay civilian network physicians for providing medical services to DOD
patients.
Appendix II: Resource Sharing at 16 Sites
Los Angeles, California
San Diego, California
estimated that the VA saves about $500,000 per year by participating in
the joint venture and an Air Force official estimated that the Air Force
saves about $300,000 per year through the joint venture.
Partners: Veterans Affairs Greater Los Angeles Healthcare System and 61st
Medical Squadron, Los Angeles Air Force Base
The Air Force contracts for mental health services from the Veterans
Affairs medical center (VAMC). According to Air Force and VA local
officials, there are two agreements in place; first, VA provides a
psychologist and a psychiatrist who provide on-site services to DOD
beneficiaries (one provider comes once a week, another provider comes 2
days a month). The total cost of this annual contract is about $200,000.
According to the Air Force, it is paying 90 percent of the CMAC rate for
these services and is thereby saving about $20,000 to $22,000 a year.
Second, the Air Force is using a VA nurse practitioner to assist with
primary care. The cost savings were not calculated but the Air Force
stated that VA was able to provide this staffing at a significantly
reduced cost as compared to contracting with the private sector.
Partners: VA San Diego Healthcare System and Naval Medical Center San
Diego
VA provides graduate medical education, pathology and laboratory testing,
and outpatient and ancillary services to the Navy. According to Navy
officials, the sharing agreements resulted in a cost reduction of about
$100,000 per year for fiscal years 2002 and 2003. As of June 2004, VA and
the Navy were in the process of finalizing agreements for sharing
radiation therapy, a blood bank, and mammography services.
In fiscal year 2003, San Diego was selected as a pilot location for the
VA/DOD Consolidated Mail Outpatient Pharmacy (CMOP) program.2 A naval
official at San Diego considers the pilot a success at this location
2VA and DOD are conducting a pilot test to provide DOD beneficiaries with
a mail-order pharmacy benefit. Under the pilot, VA's CMOP program located
in Leavenworth, Kansas will refill prescription medications on an
outpatient basis for DOD beneficiaries who had their original
prescriptions filled at the Darnall Army Community Hospital, Fort Hood,
Texas; the Naval Medical Center, San Diego, California; or the 377th
Medical Group, Kirtland Air Force Base, New Mexico.
Appendix II: Resource Sharing at 16 Sites
because participation was about 75 percent and it helped eliminate
traffic, congestion, and parking problems associated with beneficiaries on
the Navy's medical campus who come on site for medication refills-an
average of 350 patients per day. According to a DOD official, the CMOP
pilot in San Diego will likely continue through fiscal year 2004.
Key West, Florida
Pensacola, Florida
Partners: VA Miami Medical Center and Naval Hospital Jacksonville
VA and the Navy have shared space and services since 1987. The Key West
Clinic became a joint venture location in 2000. VA physically occupies 10
percent of the Navy clinic in Key West. The clinic is a primary care
facility. However, the clinic provides psychiatry, internal medicine, and
part-time physical therapy. According to Navy officials, there are two VA
physicians on call at the clinic and seven Navy physicians. The Navy's
physicians examine VA patients when needed, and the Navy bills the VA at
90 percent of CMAC. Further, VA reimburses the Navy 10 percent of the
total cost for housekeeping and utilities. VA and the Navy share
laboratory and pathology, radiology, optometry, and pharmacy services. The
VA reimburses the Navy $4 for the packaging and dispensing of each
prescription.
Partners: VA Gulf Coast Veterans Health Care System and Naval Hospital
Pensacola
Since 2000, the Navy has provided services to VA beneficiaries at its
hospital through sharing agreements that include emergency room services,
obstetrics, pharmacy services, inpatient care, urology, and diagnostic
services. In turn, VA provides mental health and laundry services to Navy
beneficiaries.
In fiscal year 2002, the Naval Hospital Pensacola met about 88 percent of
VA's inpatient needs. The Navy provided 163 emergency room visits, 112
outpatient visits, and 8 surgical procedures for orthopedic services to VA
beneficiaries. Through this agreement VA has reduced its reliance on
civilian providers, thus lowering its purchased care cost by about
$385,000 annually. Further, according to a VA official, the agreement has
allowed VA to modify its plans to build a new hospital to meet increasing
veteran demand for health care services. Rather than build a new hospital
VA intends to build a clinic to meet outpatient needs. Using VA's cost per
square foot estimates for hospital and clinic construction, the agency
Appendix II: Resource Sharing at 16 Sites
Honolulu, Hawaii
estimates that it will cost $45 million3 to build a new clinic compared to
$100 million for a new hospital.
Partners: VA Pacific Islands Healthcare System and Tripler Army Medical
Center
VA and the Army entered into a joint venture in 1991. According to VA and
Army officials, over $50 million were saved in construction costs when VA
built a clinic adjacent to the existing Army hospital. According to a VA
official, the Army hospital is the primary facility for care for most VA
and Army beneficiaries. The Army provides VA beneficiaries with access to
the following services: inpatient care, intensive care, emergency room,
chemotherapy, radiology, laboratory, dental, education and training for
physicians, and nurses. Also, as part of the joint venture agreement, VA
physicians are assigned to the Army hospital to provide care to VA
patients. VA and the Army provided services to about 18,000 VA
beneficiaries in 2003.
According to an Army official, the joint venture as a whole provides no
savings to the Army. The benefit to the Army is assured access for its
providers to clinical cases necessary for maintenance of clinical skills
and Graduate Medical Education through the reimbursed workload.
North Chicago, Illinois
Partners: North Chicago VA Medical Center and Naval Hospital Great Lakes
VA provides inpatient psychiatry and intensive care, and outpatient clinic
visits, for example, pulmonary care, neurology, gastrointestinal care,
diabetic care, occupational and physical therapy, speech therapy,
rehabilitation, and diagnostic tests to Navy beneficiaries. VA also
provides medical training to Naval corpsmen, nursing staff, and dental
residents. The Navy provides selected surgical services for VA
beneficiaries such as joint replacement surgeries and cataract surgeries.
In addition, as available, the Navy provides selected outpatient services,
mammograms,
3Authorization for the construction of the clinic was given in Pub. L. No.
108-170, Section 211, 117 Stat. 2042, 2048. The statute provides that
funding for the construction must come either from funds appropriated for
2004, or funds appropriated before 2004 for construction and major
projects that are still available. Pub. L. No. 108-170, S:214, 117 Stat.
2049.
Appendix II: Resource Sharing at 16 Sites
magnetic resonance imaging (MRI) examinations, and laboratory tests. The
2-year cost under this agreement from October 2001 through September 2003
is about $295,000 for VA and about $502,000 for the Navy. According to VA
officials, VA and DOD pay each other 90 percent of the CMAC rate for these
services. As a result, for the 2-year period VA and DOD reduced their
costs by about $88,000 through this agreement, as opposed to contracting
with the private sector for these services. VA officials also stated that
other benefits were derived from these agreements, including sharing of
pastoral care, pharmacy support, educational and training opportunities,
imaging, and the collaboration of contracting and acquisition
opportunities, all resulting in additional services being provided to
patients at an overall reduced cost, plus more timely and convenient care.
According to VA, in October 2003 the Navy transferred its acute inpatient
mental health program to North Chicago VA medical center, where staff
operate a 10-bed acute mental health ward, which has resulted in an
estimated cost reduction of $323,000. This unit also included a 10-bed
medical hold unit.
Further, VA and the Navy are pursuing a joint venture opportunity planned
for award in fiscal year 2004, which will integrate the medical and
surgical inpatient programs. This will result in the construction of four
new operating rooms and the integration of the acute outpatient evaluation
units at VA. The Navy would continue to provide surgical procedures and
related inpatient follow-up care for Navy patients at the VA facility. The
joint venture would eliminate the need for the Navy to construct
replacement inpatient beds as part of the Navy's planned Great Lakes Naval
hospital replacement facility. According to VA, this joint venture would
result in an estimated cost reduction of about $4 million.
Louisville, Kentucky
Partners: VA Medical Center Louisville and Ireland Army Community
Hospital, Ft. Knox
Since 1996, in Louisville, Kentucky, VA and the Army have been engaged in
sharing activities to provide services to beneficiaries that include
primary care, acute care pharmacy, ambulatory, blood bank, intensive care,
pathology and laboratory, audiology, podiatry, urology, internal medicine,
and ophthalmology. For fiscal year 2003, a local VA official estimated
that VA reduced its cost by $1.7 million as compared to acquiring the same
services in the private sector through its agreements with the Army; he
also estimated that the Army reduced its cost by about $1.25 million as
Appendix II: Resource Sharing at 16 Sites
compared to acquiring the same services in the private sector. As an
example of the site's efforts to improve access to care, in 2003 VA and
DOD jointly leased an MRI unit. The unit eliminates the need for
beneficiaries to travel to more distant sources of care. A Louisville VA
official stated that the purchase reduced the cost by 20 percent as
compared to acquiring the same services in the private sector.
Las Vegas, Nevada
Partners: VA Southern Nevada Healthcare System and 99th Medical Group,
Nellis Air Force Base
In this joint venture, VA and the Air Force operate an integrated medical
hospital. Prior to 1994, VA had no inpatient capabilities in Las Vegas.
This required VA beneficiaries to travel to VA facilities in Southern
California for their inpatient care. This joint venture also improved
access to specialized providers for DOD beneficiaries. The following
services are available at the joint venture: anesthesia, facility and
acute care pharmacy, blood bank, general surgery, mental health, intensive
care, mammography, obstetrics and gynecology, orthopedics, pathology and
laboratory, vascular surgery, plastic surgery, cardiology, pulmonary,
psychiatry, ophthalmology, urology, podiatry, computed tomography scan,
MRI, nuclear medicine, emergency medicine and emergency room, and
pulmonary and respiratory therapy. VA and Air Force officials estimate
that the joint venture reduces their cost of health care delivery by over
$15 million annually.4 Currently, the site is in the process of enlarging
the hospital's emergency room.
According to a VA official, during periods of heightened security,
veterans seeking treatment from the hospital at Nellis Air Force base in
Las Vegas must park outside the base perimeter, undergo a security
screening, and wait for shuttle services to take them to the hospital for
care.
4On May 7, 2004, the Secretary of Veterans Affairs announced that a new VA
medical center would be opened in Las Vegas, NV. According to the
Secretary, VA will continue to its sharing activities with DOD in Las
Vegas, NV.
Appendix II: Resource Sharing at 16 Sites
Albuquerque, New Mexico
Partners: New Mexico VA Health Care System and 377th Medical Group,
Kirtland Air Force Base
According to VA and Air Force officials, Albuquerque is the only joint
venture site where VA provides the majority of health care to Air Force
beneficiaries. The Air Force purchases all inpatient clinical care
services from the VA. The Air Force also operates a facility, including a
dental clinic adjacent to the hospital. According to an Air Force
official, for fiscal year 2003 the Air Force avoided costs of about
$1,278,000 for inpatient, outpatient, and ambulatory services needs. It
also avoided costs of about $288,000 for emergency room and ancillary
services. The Air Force official estimates that under the joint venture it
has saved about 25 percent of what it would have paid in the private
sector. Further, according to the Air Force official, additional benefits
are derived from the joint venture that are important to beneficiaries
such as: 1) continuity of care, 2) rapid turnaround through the referral
process, 3) easier access to specialty providers, and 4) an overall
increase in patient satisfaction.
Additionally, both facilities individually provide women's health (primary
care, surgical, obstetrics and gynecology) to their beneficiaries. The Air
Force official reported in March 2004 that they were evaluating how they
can jointly provide these services. In fiscal year 2003 Kirkland Air Force
Base was selected as a pilot location for the CMOP program. According to a
DOD official, the CMOP pilot at Kirtland Air Force Base will likely
continue through fiscal year 2004.
Fayetteville, North Partners: Fayetteville VA Medical Center and Womack
Army Medical Center, Fort Bragg
Carolina According to a VA official, VA and Army shared resources include
blood services, general surgery, pathology, urology, the sharing of one
nuclear medicine physician, one psychiatrist, a dental residency program,
and limited use by VA of an Army MRI unit.
Charleston, South Partners: Ralph H. Johnson VA Medical Center and Naval
Hospital Charleston
Carolina According to Navy officials, with the downsizing of the Naval
Hospital Charleston and transfer of its inpatient workload to Trident
Health Care system (a private health care system), VA and the Navy no
longer share inpatient services, except in cases where the Navy requires
mental health
Appendix II: Resource Sharing at 16 Sites
El Paso, Texas
San Antonio, Texas
inpatient services. However, in June 2004, VA has approved a minor
construction joint outpatient project totaling $4.9 million (scheduled for
funding in fiscal year 2006 with activation planned for fiscal year 2008).
Design meetings are underway. Among the significant sharing opportunities
for this new facility are laboratory, radiology, and specialty services.
Partners: El Paso VA Health Care System and William Beaumont Army Medical
Center, Fort Bliss
In this joint venture, the VA contracts for emergency department services,
specialty services consultation, inpatient services for medicine, surgery,
psychiatric, and intensive care unit from the Army. The Army contracts for
backup services from the VA including computerized tomography, and
operating suite access. According to VA officials, the Army provides all
general and vascular surgery services so that no veteran has to leave El
Paso for these services. This eliminates the need for El Paso's veterans
to travel over 500 miles round-trip to obtain these surgical procedures
from the Albuquerque VAMC-the veterans' closest source of VA medical care.
The Army provides these services at 90 percent of the CMAC rate or in some
cases at an even lower rate.
According to a VA official in June 2004, VA and the Army have agreed to
proceed with a VA lease of the 7th floor of the William Beaumont Army
Medical Center. VA would use the space to operate an inpatient psychiatry
ward and a medical surgery ward. VA will staff both wards.
In fiscal year 2004 El Paso was approved as a pilot location for testing a
system that stores VA and DOD patient laboratory results electronically.
Partners: South Texas Veterans Health Care System; Wilford Hall Medical
Center, Lackland Air Force Base; and Brooke Army Medical Center, Fort Sam
Houston
As of March 2004, a VA official stated that VA and DOD have over 20 active
agreements in place in San Antonio. Some of the sharing activities between
VA and the Air Force include radiology, maternity, laboratory, general
surgery, and a blood bank. Since 2001, VA staffs the blood bank and the
Air Force provides the space and equipment-the blood bank provides
services to VA and Air Force beneficiaries. According to VA, the blood
bank agreement saves VA and DOD about $400,000 per year.
Appendix II: Resource Sharing at 16 Sites
Further, according to Air Force officials, as of June 2004 VA and the Air
Force were negotiating to jointly operate the Air Force's ICU. The Air
Force would supply the acute beds and VA would provide the staff. This
joint unit would provide services to both beneficiary populations.
In addition, VA and Army agreements include the following areas of
service: gynecology, sleep laboratory, radiology, and laundry. According
to VA officials, VA entered into a laundry service agreement with Brooke
Army Medical Center in 2002 to utilize some of VA's excess laundry
capacity. Under the contract VA processes about 1.7 million pounds of
laundry each year for the Army at an annual cost of $875,000.
Puget Sound, Washington
Partners: VA Puget Sound Health Care System and Madigan Army Medical
Center, Ft. Lewis
As of June 2004, VA and the Army have two sharing agreements in place that
encompass several shared services. For example, the Army provides VA
beneficiaries with emergency room, inpatient, mammography, and cardiac
services. The VA provides the Army with computer training services,
laboratory testing, and radiology and gastrointestinal physician services
on-site at Madigan. In addition, VA nursing and midlevel staff provide
support to the Army inpatient medicine service. In turn, the Army provides
15 inpatient medicine beds for veterans.
During fiscal year 2002, VA paid the Army $900 per ward day per patient
for inpatient care and $1,720 per ICU day. During fiscal year 2002, there
were 69 VA patients discharged, with 117 ward days and 101 ICU days,
averaging $1,280 per day. According to VA officials, this agreement
resulted in a cost reduction, in that to contract with private providers
the average cost per day would have been $1,939. The cost reduction to VA
was $143,752. The VA and Army jointly staff clinics for otolaryngology
(1/2 day per week) and ophthalmology (3 half-day clinics per month). This
agreement results in a cost reduction of about $25,000 per year to VA
compared to contracting with the private sector. Other services such as
mammography do not result in a cost reduction, but according to VA
officials they provide their beneficiaries with another source for
accessing care.
Appendix III: Comments from the Department of Veterans Affairs and the
Department of Defense
Appendix III: Comments from the Department of Veterans Affairs and the
Department of Defense Appendix III: Comments from the Department of
Veterans Affairs and the Department of Defense Appendix III: Comments from
the Department of Veterans Affairs and the Department of Defense Appendix
III: Comments from the Department of Veterans Affairs and the Department
of Defense
Related GAO Products
Computer-Based Patient Records: VA and DOD Efforts to Exchange Health Data
Could Benefit from Improved Planning and Project Management. GAO-04-687.
Washington, D.C.: June 7, 2004.
Computer-Based Patient Records: Improved Planning and Project Management
Are Critical to Achieving Two-Way VA-DOD Health Data Exchange.
GAO-04-811T. Washington, D.C.: May 19, 2004.
Computer-Based Patient Records: Sound Planning and Project Management Are
Needed to Achieve a Two-Way Exchange of VA and DOD Health Data.
GAO-04-402T. Washington, D.C.: March 17, 2004.
DOD and VA Health Care: Incentives Program for Sharing Resources.
GAO-04-495R. Washington, D.C.: February 27, 2004.
Veterans Affairs: Post-hearing Questions Regarding the Departments of
Defense and Veterans Affairs Providing Seamless Health Care Coverage to
Transitioning Veterans. GAO-04-294R. Washington, D.C.: November 25, 2003.
Computer-Based Patient Records: Short-Term Progress Made, but Much Work
Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health
Systems. GAO-04-271T. Washington, D.C.: November 19, 2003.
DOD and VA Health Care: Access for Dual Eligible Beneficiaries.
GAO03-904R. Washington, D.C.: June 13, 2003.
VA and Defense Health Care: Increased Risk of Medication Errors for Shared
Patients. GAO-02-1017. Washington, D.C.: September 27, 2002.
VA and Defense Health Care: Potential Exists for Savings through Joint
Purchasing of Medical and Surgical Supplies. GAO-02-872T. Washington,
D.C.: June 26, 2002.
DOD and VA Pharmacy: Progress and Remaining Challenges in Jointly Buying
and Mailing Out Drugs. GAO-01-588. Washington, D.C.: May 25, 2001.
Computer-Based Patient Records: Better Planning and Oversight By VA, DOD,
and IHS Would Enhance Health Data Sharing. GAO-01-459. Washington, D.C.:
April 30, 2001.
Related GAO Products
VA and Defense Health Care: Evolving Health Care Systems Require
Rethinking of Resource Sharing Strategies. GAO/HEHS-00-52. Washington,
D.C.: May 17, 2000.
VA and Defense Health Care: Rethinking of Resource Sharing Strategies is
Needed. GAO/T-HEHS-00-117. Washington, D.C.: May 17, 2000.
VA/DOD Health Care: Further Opportunities to Increase the Sharing of
Medical Resources. GAO/HRD-88-51. Washington D.C.: March 1, 1988.
Legislation Needed to Encourage Better Use of Federal Medical Resources
and Remove Obstacles To Interagency Sharing. HRD-78-54. Washington D.C.:
June 14, 1978.
GAO's Mission The Government Accountability Office, the audit, evaluation
and investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people. GAO
examines the use of public funds; evaluates federal programs and policies;
and provides analyses, recommendations, and other assistance to help
Congress make informed oversight, policy, and funding decisions. GAO's
commitment to good government is reflected in its core values of
accountability, integrity, and reliability.
Obtaining Copies of The fastest and easiest way to obtain copies of GAO
documents at no cost
is through GAO's Web site (www.gao.gov). Each weekday, GAO postsGAO
Reports and newly released reports, testimony, and correspondence on its
Web site. To Testimony have GAO e-mail you a list of newly posted products
every afternoon, go to
www.gao.gov and select "Subscribe to Updates."
Order by Mail or Phone The first copy of each printed report is free.
Additional copies are $2 each. A check or money order should be made out
to the Superintendent of Documents. GAO also accepts VISA and Mastercard.
Orders for 100 or more copies mailed to a single address are discounted 25
percent. Orders should be sent to:
U.S. Government Accountability Office 441 G Street NW, Room LM Washington,
D.C. 20548
To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061
To Report Fraud, Contact:
Waste, and Abuse in Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: [email protected] Programs Automated answering system: (800)
424-5454 or (202) 512-7470
Congressional Gloria Jarmon, Managing Director, [email protected] (202)
512-4400 U.S. Government Accountability Office, 441 G Street NW, Room 7125
Relations Washington, D.C. 20548
Public Affairs Jeff Nelligan, Managing Director, [email protected] (202)
512-4800 U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548
Presorted Standard Postage & Fees Paid GAO Permit No. GI00
United States
Government Accountability Office
Washington, D.C. 20548-0001
Official Business
Penalty for Private Use $300
Address Service Requested
*** End of document. ***