VA and Indian Health Service: Actions Needed to Strengthen Oversight and Coordination of Health Care for American Indian and Alaska Native Veterans

A 2010 MOU set mutual goals for VA and IHS collaboration and coordination related to serving AI/AN veterans. Under this MOU, VA has established reimbursement agreements with IHS and tribal health programs to pay for care provided to AI/AN veterans. In 2013 and 2014, GAO issued two reports on VA and IHS implementation and oversight of the MOU.

GAO was asked to provide updated information related to the agencies' MOU oversight. This report examines (1) VA and IHS oversight of MOU implementation since 2014, (2) the use of reimbursement agreements to pay for AI/AN veterans' care since 2014, and (3) key issues identified by selected VA, IHS, and tribal health program facilities related to coordinating AI/AN veterans' care.

To conduct this work, GAO reviewed VA and IHS documents, reports, and reimbursement data from 2014 through 2018. GAO interviewed VA and IHS officials at the headquarters level, and officials at 15 VA, IHS, and tribal facilities in four states—Alaska, New Mexico, North Carolina, and Oklahoma—selected based on factors including the number of reported AI/AN veterans served, and geographic diversity. GAO also interviewed organizations representing tribes and tribal health programs.

The Department of Veterans Affairs (VA) and the Department of Health and Human Services' (HHS) Indian Health Service (IHS) established a memorandum of understanding (MOU) to improve the health status of American Indian and Alaska Native (AI/AN) veterans through coordination and resource sharing among VA, IHS, and tribes. Since GAO's last report on the topic in 2014, VA and IHS have continued to jointly oversee the implementation of their MOU—for example, through joint workgroups and quarterly meetings and reports—but they lack sufficient measures for assessing progress towards MOU goals. Specifically, while the agencies established 15 performance measures, they did not establish targets against which performance could be measured. For example, while the number of shared VA-IHS trainings and webinars is a performance measure, there is no target for the number of shared trainings VA and IHS plan to complete each year. GAO's work on best practices for measuring program performance has found that measures should have quantifiable targets to help assess whether goals and objectives were achieved by comparing projected performance and actual results. VA and IHS officials said they are currently in the process of revising the MOU and updating the performance measures used. However, officials have not indicated that any revised measures will include targets.

Total reimbursements by VA for care provided to AI/AN veterans increased by about 75 percent from fiscal year 2014 to fiscal year 2018. This increase mainly reflects the growth in reimbursement from VA to tribal health program facilities—facilities that receive funding from IHS, but are operated by tribes or tribal organizations. Similarly, the number of VA's reimbursement agreements with tribal health programs and the number of AI/AN veterans served under the reimbursement agreements also increased during this period.

The VA, IHS, and tribal facility officials GAO spoke with described several key challenges related to coordinating care for AI/AN veterans. For example, facilities reported conflicting information about the process for referring AI/AN veterans from IHS or tribal facilities to VA, and VA headquarters officials confirmed that there is no national policy or guide on this topic. One of the leading collaboration practices identified by GAO is to have written guidance and agreements to document how agencies will collaborate. Without a written policy or guidance about how referrals from IHS and tribal facilities to VA facilities should be managed, the agencies cannot ensure that VA, IHS, and tribal facilities have a consistent understanding of the options available for referrals of AI/AN veterans to VA specialty care. This could result in an AI/AN veteran receiving, and the federal government paying for, duplicative tests if the veteran is reassessed by VA primary care before being referred to specialty care.

GAO is making three recommendations—one each to VA and IHS to establish measurable targets for performance measures and one to VA to establish written guidance for referring AI/AN veterans to VA facilities for specialty care. VA and HHS concurred with these recommendations.

American Indians and Alaska Natives (AI/AN) have served in the military  at a higher rate than members of other racial groups at various points in  history, yet AI/AN veterans are more likely than other veterans to lack  health insurance or have a service-connected disability. Once separated  from the military, some AI/AN veterans are eligible to receive health care  services from both the Department of Veterans Affairs (VA) and the  Indian Health Service (IHS), an agency within the Department of Health  and Human Services. VA and IHS each operate their own health care  facilities. AI/AN veterans also may receive care from facilities that are  operated by tribes or tribal organizations, known as tribal health programs  (THPs), which received about 54 percent of IHS’s budget in 2017.

In 2010, VA and IHS expanded upon a 2003 memorandum of  understanding (MOU) to improve the health status of AI/AN veterans  through coordination and resource sharing among VA, IHS, and tribes.  This 2010 MOU outlined mutual goals for VA and IHS collaboration and  coordination of resources and health care services provided to AI/AN  veterans. For example, it included provisions for joint contracts and  purchasing agreements, sharing staff, ensuring providers in VA and IHS  could access the electronic health records of shared patients, and the  development of reimbursement policies and mechanisms to support care  delivered to AI/AN veterans eligible for care in both systems. In  December 2012, VA and IHS signed a reimbursement agreement that  facilitates reimbursement from VA to IHS facilities for the direct care  services they provide to eligible AI/AN veterans. VA has established  similar reimbursement agreements with THPs.

In 2013 and 2014, we reported on the agencies’ collaboration on efforts  related to the MOU, including progress on meeting MOU goals. Our  2013 report found that while VA and IHS had developed mechanisms to  implement and monitor MOU-related activities, there were inadequacies  with the performance measures used to measure MOU progress, and  ineffective consultation with tribes regarding the MOU. Our 2014 report  found that while VA and IHS had taken a variety of actions under the  MOU to improve access to care for AI/AN veterans, MOU oversight was  inconsistent, written guidance and policies were lacking, and leadership  had not prioritized MOU implementation. We made several  recommendations to VA and IHS aimed at improving MOU  implementation and oversight, which the agencies agreed with and  subsequently implemented.

You asked us to provide updated information related to the agencies’  efforts to implement the MOU, including the use of reimbursement  agreements, since the issuance of our June 2014 report, and to examine  issues related to care coordination among VA, IHS, and THP facilities.  This report examines  1.  the extent to which VA and IHS have continued to oversee  implementation of their MOU since 2014;  2.  the use of reimbursement agreements for VA to pay for AI/AN  veterans’ care at IHS and THP facilities since 2014; and  3.  key issues related to coordinating care for AI/AN veterans, as  identified by selected VA, IHS, and THP facilities.

To address these three objectives, we interviewed federal and tribal  officials at the national and local levels. We interviewed VA and IHS  headquarters officials, including officials from VA’s Office of Rural Health  and Office of Tribal Government Relations, and IHS’s Office of the  Director. We also interviewed representatives from national and regional  organizations representing AI/AN tribal organizations and health  programs. Additionally, to obtain the perspective of selected VA, IHS,  and THP facilities, we interviewed officials from 15 facilities (4 VA  facilities, 3 IHS facilities, and 8 THP facilities) in four states—Alaska, New  Mexico, North Carolina, and Oklahoma. We selected a mix of both IHS  and THP facilities, and ensured they reflected geographic diversity as well  as variation in the number of AI/AN veterans they served (according to  VA reimbursement data through September 2017). We selected the 4  VA facilities because they were the facilities with which our selected IHS  and THP facilities had signed reimbursement agreements. We also  interviewed officials in the five IHS areas in which the IHS and THP  facilities were located. VA regional officials participated in two of the VA  facility interviews. Our findings from these interviews are not  generalizable to all VA, IHS, or THP facilities.

To examine the extent to which VA and IHS have continued to oversee  implementation of their MOU since 2014, we reviewed the MOU and a  broad range of documents related to MOU activities, such as monthly and  annual reports and quarterly meeting minutes. These describe MOU- related activities and progress by VA and IHS on MOU goals and  performance measures. We compared this evidence to relevant criteria  from our past work on leading practices for interagency collaboration, and  assessed the MOU performance measures against our work on the key  attributes of successful performance measures. We also reviewed the  actions taken by VA and IHS in response to our 2013 recommendation  about improving MOU performance measures.

To examine the use of reimbursement agreements for VA to pay for  AI/AN veterans’ care at IHS and THP facilities since 2014, we reviewed  and summarized reimbursement agreements data from VA reports,  including data on veterans served at IHS and THP facilities, amounts  reimbursed by VA to IHS and THP facilities, and number of prescriptions  filled by VA for patients at IHS and THP facilities in fiscal years 2014  through 2018. We assessed the reliability of the VA reimbursement data  by interviewing knowledgeable VA officials, reviewing supporting  documentation, and reviewing the data for obvious errors or outliers. We  determined these data were sufficiently reliable for our purposes. We also  reviewed and analyzed information from VA to determine the length of  time it took the department to enter reimbursement agreements with  THPs. Additionally, we reviewed other documents, such as the  reimbursement agreement between VA and IHS, and the reimbursement  agreements between VA and our selected THPs.

To examine the key issues related to coordinating care for AI/AN  veterans, as identified by selected VA, IHS, and THP facilities, we utilized  our interviews with officials at the 15 selected facilities. As applicable, we  also reviewed available VA and IHS data related to some of the  coordination issues raised in these interviews. We examined the available  data on coordination issues and assessed its reliability by interviewing  knowledgeable officials, reviewing supporting documentation, and  reviewing the data for obvious errors. We determined that the data we  report were sufficiently reliable for our audit objectives. As applicable, we  assessed the key issues described against relevant criteria in the MOU  itself, or our past work on leading practices for interagency  collaboration.

We conducted this performance audit from October 2017 through March  2019 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  the evidence obtained provides a reasonable basis for our findings and  conclusions on our audit objectives.

The number of AI/AN veterans eligible for both VA and IHS services is  unknown. The U.S. Census Bureau estimates that in 2017 approximately  141,000 AI/AN individuals identified themselves as veterans. This  estimate includes only individuals who identified as AI/AN alone and not  in combination with another racial group. IHS and VA do not have an  administrative mechanism for determining the number of AI/AN veterans  who are users of both systems. Instead, each agency separately relies on  individuals to identify either as veterans, or as AI/AN, resulting in different  counts. Specifically, according to IHS, in fiscal year 2017, 48,169 active  IHS users self-identified as veterans. According to VA, in fiscal year  2017, 80,507 VA-enrolled veterans self-identified as AI/AN.

VA is charged with providing health care services to the nation’s eligible  veterans, and served 6.8 million veterans in fiscal year 2017 with a total  health care budget of about $69 billion. VA’s health care system includes  18 regional networks—Veterans Integrated Service Networks—to which  each of VA’s facilities is assigned. VA has 170 medical centers, which  offer a variety of inpatient and outpatient services, ranging from routine  examinations to complex surgical procedures. VA’s health care system  also includes community-based outpatient clinics and other facilities that  generally limit services to primary care and some specialty care. When  needed services are not available at VA facilities or within required driving  distances or time frames, VA may purchase care from non-VA providers  through its community care programs, such as the Veterans Choice  Program. Eligibility for VA health care is based on several factors,  including the veteran’s period of active service, discharge status, the  presence of service connected disabilities or exposures, income, and  other factors. VA uses factors such as these to categorize eligible  veterans into eight enrollment priority groups—established to manage the  provision of care. Some veterans qualify for free health care services  based on service connected disabilities, income, or other special  eligibilities, while others may be responsible for co-payments.

IHS was established to provide health services to members of AI/AN  tribes, and its facilities are primarily in rural areas on or near reservations.  IHS’s fiscal year 2017 budget was approximately $5 billion, and the  agency served about 1.6 million individuals. The agency is organized into  12 federally designated geographic areas. IHS provides services  directly through a federally operated network of 25 hospitals, 53 health  centers, and 30 health stations in 37 U.S. states. In addition, about 54  percent of IHS’s funds are provided to THPs to operate about 580 of their  own facilities such as hospitals, health centers, clinics and health stations.  IHS also provides funding to 41 nonprofit organizations through the Urban  Indian Health program to provide health care services to AI/AN individuals  living in urban areas.

IHS and THP facilities are often limited to providing primary and  emergency care services. When needed health care services are not  available at IHS or THP facilities, in certain circumstances the facilities  may pay external providers to provide these services through IHS’s  Purchased/Referred Care (PRC) program. Before the PRC program can  provide payment, patients must exhaust all health care resources  available to them from private insurance, state health programs, and  other federal programs, including VA. Furthermore, eligibility for PRC  payment is not automatic, and IHS has reported that PRC funds are not  sufficient to pay for all necessary care and, therefore, generally pay for  only the highest priority costs, such as emergency care and transportation  to that care.

To be eligible for IHS health care services, an individual must generally  be a member or descendant of one of the current 573 federally  recognized Indian tribes, as evidenced by such factors as tribal  membership, enrollment, residence on tax-exempt land, ownership of  restricted property, active participation in tribal affairs, or other relevant  factors. In instances where an AI/AN veteran is eligible for a particular  health care service from both VA and IHS, VA is the primary payer.

The VA and IHS MOU and Reimbursement Agreements

The 2010 MOU between VA and IHS set mutual goals and objectives to  facilitate coordinating and resource-sharing between the two agencies.  Specifically, the five MOU goals are as follows:  1.  Increase access to and improve quality of health care and services to  the mutual benefit of both agencies. Effectively leverage the  strengths of the VA and IHS at the national and local levels to afford  the delivery of optimal clinical care.  2.  Promote patient-centered collaboration and facilitate communication  among VA, IHS, AI/AN veterans, tribal facilities, and Urban Indian  clinics.  3.  In consultation with tribes at the regional and local levels, establish  effective partnerships and sharing agreements among VA  headquarters and facilities, IHS headquarters and facilities, tribal  facilities, and Urban Indian Health Programs in support of AI/AN  veterans.  4.  Ensure that appropriate resources are identified and available to  support programs for AI/AN veterans.  5.  Improve health promotion and disease prevention services to AI/AN  veterans to address community-based wellness.

In accordance with these five goals, the MOU contains specific areas in  which VA and IHS agreed to collaborate and coordinate, including:

Reimbursement: development of payment and reimbursement policies  and mechanisms to support care delivered to dually eligible AI/AN  veterans.

Sharing staff: sharing of specialty services, joint credentialing and  privileging of health care staff, and arranging for temporary  assignment of IHS Public Health Service commissioned officers to  VA.

Staff training: providing systematic training for VA, IHS, THP, and  Urban Indian Health Program staff on VA and IHS eligibility  requirements to assist them with appropriate referrals for services.

Information Technology Interoperability: interoperability of systems to  facilitate sharing of information on common patients, and  establishment of standard mechanisms for VA, IHS, and THP  providers to access records for patients receiving care in multiple  systems.

VA and IHS each designated certain staff to oversee and implement the  MOU, but VA is generally responsible for administering the MOU. For  example, VA’s Office of Community Care provides oversight of the  reimbursement agreements—which are a key part of the MOU. Within  that office, VA established the IHS/THP Reimbursement Agreements  Program to carry out portions of the MOU related to the development of  payment and reimbursement policies. Under these policies, in instances  where an AI/AN veteran is eligible for a particular health care service from  a VA facility, that veteran can instead receive the eligible service at an  IHS or THP facility without prior VA approval and, under a reimbursement  agreement, VA will reimburse the facility for the service. Some key  aspects of the reimbursement agreement program are as follows:

All IHS facilities are covered under one national reimbursement  agreement between VA and IHS.

THPs each negotiate their own separate reimbursement agreements  with VA. While VA uses a reimbursement agreement template based  on the agreement with IHS, the terms of each THP agreement may  deviate from those in IHS’s national agreement.

Urban Indian Health Programs are generally not eligible for  reimbursement agreements.

VA provides reimbursement for outpatient and inpatient direct care  services provided at IHS and THP facilities.

VA also reimburses IHS and THP facilities for costs of outpatient  prescriptions for AI/AN veterans, as well as filling prescriptions for  AI/AN veterans served at IHS and THP facilities through VA’s  Consolidated Mail Outpatient Pharmacy program.

VA does not provide reimbursement for those services from external  providers paid for by IHS or THP PRC programs.

VA reports that the process of establishing reimbursement agreements  with THPs has multiple phases. The process begins with initial  communication between the THP and VA, followed by an orientation  briefing. The THP then begins to draft the agreement (based on VA’s  template) and prepare required VA paperwork (e.g., an implementation  plan and proof of certification or accreditation). Once drafted, the THP  submits the draft agreement and paperwork for review by VA’s IHS/THP  Reimbursement Agreements Program, followed by review by a VA  contracting officer and legal team. The agreement is complete once it is  signed by VA and the THP.

VA and IHS Continue to Jointly Oversee the MOU, but Gaps Exist in Measuring Performance

A joint leadership team of VA and IHS officials continues to oversee the  implementation of the 2010 MOU through meetings, regular reporting,  and the establishment of goals and measures to assess performance— but these measures lack targets for assessing progress toward the goals.  VA and IHS officials also told us they are drafting a revised MOU to be  broader and more flexible than the existing MOU and are updating the  performance measures. However, officials have not indicated that any  revised measures will include targets.

VA and IHS Have Continued to Carry Out MOU Oversight Activities and Implementation, and Are in the Process of Revising the MOU

Since our last report in 2014, a joint national leadership team comprised  of VA and IHS officials has continued to use quarterly meetings, routine  reporting, and MOU goals and measures to oversee MOU implementation  and help facilitate collaboration. VA and IHS officials told us that the  leadership team consists of officials in VA’s Office of Rural Health and  Office of Tribal Government Relations, and the IHS Deputy Director for  Intergovernmental Affairs. Specifically, the leadership team has met to  discuss the progress and status of the MOU, develop implementation  policy and procedures, create performance measures and timelines, and  evaluate progress on those measures. The leadership team also  compiles annual reports on progress in MOU implementation that  includes information about activities and challenges on meeting MOU  goals using established measures, and information on the reimbursement  agreements and outpatient pharmacy program. In addition, VA and IHS  issue monthly data reports on the reimbursement agreements, including  the total amount disbursed, the number of veterans receiving services  reimbursed by VA, and the number of claims processed for IHS and THP  facilities.

The leadership team receives input from workgroups tasked with the  responsibility for implementing and developing strategies to address the  goals of the MOU. The workgroups primarily consist of VA and IHS staff  who meet periodically to discuss goals and report quarterly to the  leadership team. Tribal officials have participated in some MOU  workgroups, though they are not a part of the MOU leadership team.  Since our last report in 2014, the number of workgroups decreased from  12 to three groups. (See table 1.) VA and IHS officials said that there  were a number of reasons why the number of workgroups had decreased  over time, such as consolidation into broader groups because the  missions of some groups were similar. VA officials noted that the 12  original workgroups reflected the structure of the MOU, but over time they  realized that there was not a need for workgroups in some of these areas.

With the establishment of the MOU, VA and IHS have been able to share  resources and collaborate on activities to improve access of care for  AI/AN veterans. VA and IHS reported that the MOU has helped both  agencies develop an outpatient pharmacy program for AI/AN veterans,  hold joint training and recruitment events, and establish the  reimbursement agreement program, among other accomplishments. The  VA, IHS, and THP facility officials we spoke with noted activities related to  the reimbursement agreements and a few noted improvements in areas  such as training and telehealth as a result of the MOU. However, most of  the facility officials generally reported they had not observed  improvements in national-level VA and IHS collaboration and coordination  in other areas identified by the MOU. Additionally, these facility officials  told us that their facilities have not implemented any new policies,  procedures, or any specific facility performance goals or targets that were  linked to the MOU.

VA and IHS headquarters officials acknowledged that all areas of the  MOU have not been implemented at all facilities, and noted that while  improvements have been made in many areas, organizational challenges  remain, such as in the area of information technology. One IHS  headquarters official added that even though VA and IHS have not fully  implemented all parts of the MOU, they have addressed each area of the  MOU in some manner. For example, one of the goals of the MOU is to  improve coordination of care by developing and testing innovative  approaches and disseminating best practices. IHS headquarters officials  indicated that the agency has addressed this goal in part by creating an  Improving Patient Care program that was informed by using VA  curriculum and utilizing lessons learned from VA’s Patient Aligned Care  Teams.

VA and IHS leadership said they are currently in the process of revising  the MOU to be broader and more flexible to better meet the care needs of  AI/AN veterans. Regularly monitoring and updating written agreements on  collaboration, such as the MOU, is consistent with our key collaboration  practices. IHS officials said that in contrast to the current MOU, in the  new MOU, they are not looking to delineate every area of coordination  and instead are grouping topics into broader areas of coordination. In the  fiscal year 2017 MOU annual report, VA and IHS noted they were  removing outdated language from the MOU and planned to create a more  comprehensive, flexible MOU that would serve both agencies well into the  future. VA and IHS officials indicated that these revisions will address  some areas in the current MOU that they have not yet been able to  implement. In June 2018, VA officials said that the leadership team had  decided upon a revised set of MOU goals and associated objectives. In  February 2019, VA and IHS reported that the target completion date for  the new MOU was spring 2020.

VA and IHS MOU Performance Measures Are Not Sufficient

VA and IHS have improved their efforts to measure progress towards  meeting the five MOU goals since 2014. In response to a  recommendation made in our April 2013 report, VA and IHS revised their  MOU performance measures in 2015—better aligning the measures with  the MOU goals. In addition, as a result of our work in 2013, the  agencies revised an existing data collection reporting template used to  gather information for each measure—such as the measurable objective,  rationale and intent of the measures, action plan, milestones, and  barriers—to help determine whether MOU goals were being met. While  we found that the three existing MOU workgroups had since stopped  using this template, a VA official confirmed that they believe relevant  information is still captured through its monthly and quarterly reports.

Nonetheless, while VA and IHS improved their performance  measurement efforts since our 2013 report, we found that the revised  MOU performance measures still do not have quantitative and  measurable targets to assess agency progress toward the goals. We  have previously reported that performance measures should have  numerical targets or other measurable values, which help assess whether  overall goals and objectives were achieved by easily comparing projected  performance and actual results. Besides having measureable targets,  other key attributes of successful performance measures include linkage  to an agency’s goals and mission, clarity, objectivity, and balance. None  of the 15 revised measures have targets against which performance can  be measured to assess progress and evaluate effectiveness. (The results  of our assessment are shown in table 2.) For example, while the number  of shared VA-IHS trainings and webinars is a performance measure,  there is no target for the number of shared trainings VA and IHS hope to  complete each year.

VA officials we spoke with stated VA has not considered adding targets to  these measures, noting that the nature of the measures and MOU work  against establishing targets. For example, officials said that the measures  related to the reimbursement agreements are dictated by the needs of the  population seeking health care and the providers at the IHS and THP  facilities. VA officials we spoke with said instead of targets, they assess  success or failure by whether they see incremental growth in the  measures. Officials added that they examine these measures quarterly to  determine if they have increased, decreased, or remained stable. If the  measures are stable or decrease, officials said they consider if these  trends can be reversed.

However, the absence of targets limits the ability of VA and IHS to use  these measures to assess performance. Without defined measurable  targets or goals, VA and IHS lack a clear basis for objectively and  strategically evaluating how and where improvements should be made.  For example, while it is helpful to count the number of tribal outreach  activities conducted, setting an annual target for such activities would  allow the agencies to better assess whether they are meeting their goals  in this area.

In addition, some of these measures also lacked other attributes  important for assessing performance. Specifically, five of the measures  listed the completion of an annual metric review, which is a task to  execute rather than a desired performance outcome to be measured. VA  and IHS also are not using two measures. Specifically, they have not  collected any data to track results on the number of VA and IHS  employees who attend training and on the quality of health care provided.  Relatedly, for the measure on health care quality, VA and IHS have not  developed a clear definition against which to measure performance, as  specific quality measures have not been determined and data are not  being collected.

VA and IHS have documented challenges related to confusion and  difficulty in tracking some measures; for example, at a meeting in March  2017, the MOU leadership team discussed that measures were not well  tailored to the workgroup structure at that time. IHS officials also  acknowledged that the measures currently in place are counting activities,  but not necessarily always measuring performance—such as whether  trainings held were effective. VA officials said that revising the MOU will  give them an opportunity to revisit the performance measures used, and  that they are looking to apply lessons learned to do a better job in the  future at defining the measures. Similarly, IHS officials noted that the  agencies are engaged in conversation about the performance measures  to make them more useful. However, as previously noted, VA officials  said that they have not considered establishing targets for the measures.

Use of Reimbursement Agreements Has Increased Since 2014 and IHS and THP Facilities Viewed the Agreements as Beneficial

THP facilities’ use of reimbursement agreements with VA increased from  2014 through 2018. The selected IHS and THP facilities we spoke with  viewed the reimbursement agreements as beneficial, but also identified  some concerns.

The Number of Reimbursement Agreements Entered, and the Amount of Claims Reimbursed and Veterans Served through Them, Have Increased Since 2014

The use of VA’s reimbursement agreements with THPs increased from  2014 through 2018, as measured by the number of agreements, claims  reimbursed, and veterans served. In addition, there was also an increase  in payments made for prescriptions filled through the VA’s Consolidated  Mail Outpatient Pharmacy program for AI/AN veterans receiving services  at IHS and THP facilities. As all IHS facilities are covered under a single  national agreement that was instituted prior to 2014, there was less  change in the use of reimbursement agreements by these facilities.

Reimbursement agreements entered. The number of reimbursement  agreements with THPs more than doubled from 2014 to 2018, increasing  about 113 percent. We previously reported, as of May 16, 2014, that VA  had 53 reimbursement agreements with THPs. VA data showed that as of  December 2018 it had 113 reimbursement agreements with THPs,  representing about 34 percent of the 337 total IHS-funded THPs. (See fig.  1.) VA also reported that there were 42 additional pending reimbursement  agreements with THPs that were in varying phases of submission,  processing, and review. In addition, as in 2014, IHS facilities are covered  under a single national agreement, and the number of IHS facilities  covered by it has remained similar.

In 2014, we reported that VA officials had conducted outreach through  tribal letters and events to educate THPs about the option of establishing  reimbursement agreements, and officials told us this outreach has  continued. As we reported previously, there are several reasons a THP  might decide not to have an agreement with VA, such as deciding it was  not worth the time and resources needed to establish an agreement.  Officials from a national tribal organization we spoke with said that  smaller tribes without many veterans or resources may not be interested.  IHS officials also noted that if a THP’s veteran population has alternate  payment resources (e.g., Medicaid or private insurance), it may not be  worth the steps to implement a reimbursement agreement if the THP will  not be billing VA for veterans’ services.

Amount of claims reimbursed. In fiscal year 2014, VA paid IHS and  THP facilities $11.5 million for services provided to AI/AN veterans, which  grew to $20.1 million in fiscal year 2018. This increase mainly represents  the growth in reimbursement to THP facilities—which grew 181 percent,  from $4.3 million in fiscal year 2014 to $12.1 in fiscal year 2018. During  this same time period, reimbursements to IHS facilities remained  relatively stable, reflecting the stable number of IHS facilities receiving  reimbursements. (See fig. 2.)

Veterans served. Between fiscal year 2014 and fiscal year 2018,  according to VA data, the number of unique AI/AN veterans receiving  services reimbursed by VA each year has increased from about 3,800 in  2014 to a high of nearly 5,300. (See fig. 3.) While IHS facilities accounted  for a larger percentage of veterans with reimbursed services compared to  THPs, the number of veterans receiving services reimbursed by VA at  THPs increased significantly. For fiscal year 2014, 2,965 AI/AN veterans  received services reimbursed by VA at IHS facilities, which decreased  slightly to 2,829 in fiscal year 2018. In comparison, 885 veterans received  services reimbursed by VA at THP facilities in fiscal year 2014, which  nearly tripled to 2,531 veterans in fiscal year 2018.

Prescriptions filled. Similar to increases in the numbers of AI/AN  veterans served under the reimbursement agreements, AI/AN veterans’  utilization of VA’s Consolidated Mail Outpatient Pharmacy program has  also increased. Prescriptions filled through this program more than  doubled—from more than 440,000 prescriptions in fiscal year 2014 to  nearly 886,000 prescriptions in fiscal year 2018. (See fig. 4.) VA and IHS  annual reports indicate that the pharmacy program has been one of the  most successful collaborations between VA and IHS for AI/AN veterans,  providing more than 2 million prescriptions for VA-IHS patients since the  pharmacy program collaboration began in 2010. While this program was  originally limited to AI/AN veterans served at IHS facilities, in December  2016, VA and IHS entered into an Interagency Agreement that extended  the program to THPs.

IHS and THP Facilities Viewed the Reimbursement Agreements as Beneficial, but Identified Some Concerns

Officials from the majority of IHS and THP facilities we contacted said  they were generally pleased with the reimbursement agreements. Among  those, officials from one THP noted that the revenue received from their  reimbursement agreement freed up other resources that allowed them to  hire an additional part-time worker to conduct VA outreach activities.  Additionally, a representative of a national tribal organization noted that  IHS and THP facilities’ funding is limited and this revenue helps them  extend services to eligible AI/AN veterans.

However, officials from a number of IHS and THP facilities also had  concerns about the agreements, including the lack of reimbursement for  PRC program services provided by IHS and THP facilities, the length of  time it took to enter into the agreements, and the time frames of the  agreements:  Lack of reimbursement for PRC program services. Officials at most  IHS and THP facilities we contacted said they believed VA should  reimburse facilities for services from external providers paid through the  PRC program. Officials at some facilities said they have had to deny PRC  services due to a lack of program funds. According to some facility and  IHS area office officials, this issue is particularly relevant in states where  Medicaid was not expanded under the Patient Protection and Affordable  Care Act (PPACA). In states where Medicaid eligibility was expanded,  more AI/AN individuals may therefore be eligible for Medicaid—potentially  freeing up PRC funds. For example, an IHS official noted that prior to  Medicaid expansion in his state they would have to limit PRC funds to be  used only in life or death scenarios after May or June of each year, but  that currently his facility was not limiting any PRC services. Given the  limitations in PRC program funds, officials from a national tribal  organization and some THPs noted they have raised the possibility of  including the PRC program in the reimbursement agreements with VA,  although the program was ultimately not included.

VA officials noted that there is no statutory requirement for them to  include the PRC program in the reimbursement agreements and also  identified several other reasons for not including it. For example, they said  that VA does not want to pay for services externally that it already offers  internally and that it would prefer to coordinate the patient’s care within  VA’s existing programs, such as VA’s own programs for purchasing care  from external providers—like the Veterans Choice Program.

The length of time to enter into an agreement. Officials from a few  THP facilities and one national tribal organization we spoke with noted  concerns about the amount of time it took to enter into reimbursement  agreements. Our analysis of VA reimbursement agreement data shows  that the median amount of time that it took to enter an agreement with  THPs was over 1 year (about 403 days). We found that the number of  days from the first contact by a THP to the actual signing of the  agreement ranged from 96 days (over 3 months) to 1,878 days (more  than 5 years).

According to VA records and interviews, there were reasons for delays in  completing reimbursement agreements, including lengthy negotiations,  incomplete submission of information from the THPs, lapses in  communication between VA and the THP, and a THP’s lack of medical  certification or accreditation. VA officials explained that the amount of  time increases if the THP does not want to use the VA-approved  reimbursement agreement template or wants to change the terms of the  agreement. For example, an official from one THP facility said that it took  2.5 years to finalize its reimbursement agreement due, in part, to internal  challenges with their legal counsel and external challenges with  negotiating the terms of the agreement during a time when the VA was  developing a national reimbursement agreement template. VA officials  also explained that entering the agreement with IHS was simpler than  entering agreements with THPs because it was a national agreement  between two federal agencies and, for example, did not require having a  contracting officer review the agreement—an extra step needed for  agreements with non-federal agencies.

The length of time reimbursement agreements are in effect. Officials  from a few THP facilities expressed a desire for longer reimbursement  agreements that would permit greater planning ability. The agreement  between VA and IHS was initially set for 3 years. It was then extended  twice, once for 2 years and once for 1.5 years. The time frames for THP  agreements have generally been extended consistent with extensions to  the national agreement. Officials from one THP we spoke with said that  having short-term reimbursement agreements causes problems with  internal organizational planning and it would be beneficial to have a  longer term non-expiring agreement that can be cancelled so that THPs  do not continue to expend resources to complete new agreements or  amendments every 2 years. In June 2018, VA and IHS signed an  amendment to extend the terms of the national reimbursement agreement  through June 30, 2022. VA officials said they are currently in the process  of working with THPs to similarly extend their agreements.

Facilities Cited Varying Levels of Coordination, and Key Challenges Included Making Referrals from IHS and THP Facilities to VA

In speaking to officials at selected VA, IHS, and THP facilities about key  issues related to coordinating care for AI/AN veterans, we found that the  extent of coordination they reported varied widely. For example, three IHS  and THP facilities said they had little to no care coordination with their  local VA partners; noting, for example, that they rarely refer veterans to  VA since they offer more services than the closest VA facilities. Other  facilities described more extensive and formalized care coordination,  including shared funding of certain VA and THP employees, or VA  employees on site at THP facilities to manage veterans’ care and  referrals to and from VA. In Alaska, for example, where services offered  by VA are very limited, VA instead has formal sharing and reimbursement  agreements established with 26 THPs, which provide the majority of  services to AI/AN veterans, as well as some non-Native veterans. Two of  the THP facilities we spoke with in Alaska have VA employees working on  site to help coordinate veterans’ care. VA and IHS headquarters officials  indicated that the MOU was intended to allow for variation in the level of  coordination at the local, facility level not to create demands or obligations  on facilities. One VA official noted that as the new MOU is developed,  both VA and IHS want to continue to allow VA, IHS, and THP facilities to  engage in whatever level of coordination makes sense.

Despite variation in the extent of coordination, officials identified several  common challenges regarding coordination between local VA, IHS, and  THP facilities:  Referring patients to VA facilities. Officials from 9 of the 15 VA, IHS,  and THP facilities we contacted reported conflicting information about the  process for referring AI/AN veterans from IHS and THP facilities to VA  facilities for specialty care. For example, 4 of the IHS and THP facilities  we spoke with said that AI/AN veterans generally could not be referred  directly to VA specialty care by IHS or THP providers without first being  seen and referred by a provider at VA. These facility officials indicated  that this practice was a barrier to care. These officials also noted that this  could result in the patient receiving, and the federal government paying  for, duplicative tests. However, officials at another IHS facility indicated  that IHS and THP facilities should be able to refer patients directly to VA  specialty care. Additionally, during an interview at a VA facility, local and  regional officials had differing understandings of whether IHS and THP  facilities could refer patients directly to VA specialty care.

VA and IHS headquarters officials both reported that in general, IHS or  THP facilities cannot refer a patient to VA specialty care without that  patient first being seen in VA primary care. However, VA officials reported  that there is no national policy or written guidance on how to refer patients  from an IHS or THP facility to a VA facility. VA officials said that the  coordination process is left to the local VA facility and the respective IHS  or THP facilities and the process can vary from one facility to another— explaining why differing information was reported by facility officials. Our  past work on interagency collaborative mechanisms identifies that it is a  leading collaboration practice to have written guidance and agreements to  document how agencies will collaborate. Without a written policy or  guidance about how referrals of AI/AN veterans from IHS and THP  facilities to VA facilities may be managed, VA and IHS cannot ensure that  VA, IHS, and THP facilities have a consistent understanding of the  options available for these referrals.

Information technology interoperability and access. Officials at 10 of  the 15 VA, IHS, and THP facilities we contacted cited challenges related  to accessing each other’s health information technology systems. Most  stated that a lack of interoperability of their electronic health records  caused challenges, while a few IHS and THP facilities also mentioned  that the lack of access to VA systems makes it difficult to verify a  veteran’s eligibility or determine the services for which VA will reimburse.  For example, one THP noted that if an AI/AN veteran was sent to VA for a  service, the THP provider would not receive the veteran’s follow-up  records as quickly as if they had access to each other’s systems.  Improving systems’ interoperability was a focus area identified in the  MOU, and an IHS official indicated that while the agencies had some  initial work on the topic, no systematic solutions were identified. We have  previously identified VA’s lack of systems interoperability—particularly  with the Department of Defense—as a contributor to the agency’s  challenges related to health care.

VA and IHS officials identified some potential workarounds to this lack of  interoperability, although they noted that some of the described  workarounds could be time consuming and may not be feasible for all  facilities:

An IHS headquarters official said that IHS and VA each have the  ability to request the sharing of information from an individual  electronic health record held by the other agency through secure  emails—although the official noted that this is not as fast or efficient  as being able to log in to each other’s systems.

VA officials also reported that VA belongs to the eHealth Exchange— a national health information exchange—and said that IHS or THPs  could join that, through which they would be able to access  information about common veteran patients. However, IHS reported  that although the agency explored connecting to the eHealth  Exchange several years ago, testing and onboarding costs to  participate were prohibitive. IHS noted that several individual facilities  across the IHS system have elected to invest in connections with  regional health information exchanges. Similarly, two THPs we spoke  with reported being a part of other, more locally-based health  information exchanges, but noted that VA was not part of these  exchanges.

A VA official noted that there is an enrollment guide that details how  enrollment and eligibility verification will be managed between IHS,  THP, and VA facilities. This guide describes how IHS or THP facilities  can request veterans’ enrollment and eligibility information from the  VA Health Eligibility Center using a templated spreadsheet that sends  requests via email through a secure data transfer service. VA’s Health  Eligibility Center verifies the list and returns the completed  enrollment/eligibility excel spreadsheet to the IHS or THP facility  securely. IHS and THP facilities can also contact the VA Health  Eligibility Center directly by telephone for fewer than five veterans per  call, or their local VA medical center by telephone to verify one AI/AN  veteran’s enrollment and eligibility per call.

IHS or THP facilities could also enter an arrangement with a local VA  facility to have VA employees or co-funded employees on site at IHS  or THP facilities, or to have VA-credentialed employees that can  access VA systems to share information. However, these options may  not be systemic solutions that work at all facilities. An IHS  headquarters official noted, for example, that not all IHS or THP  facilities have the type of relationship with their local VA facility that  would lead to the establishment of such arrangements.

In terms of the potential for improving interoperability in the future, VA is  in the process of implementing a new electronic health record system,  and we have previously reported that VA has identified increased  interoperability as a key expected outcome of its decision to switch  systems. Officials from two VA and THP facilities were hopeful that this  new system will help improve interoperability since some THPs use an  electronic health record system from the same company that VA has a  contract with. Additionally, an IHS headquarters official said that IHS is  also reevaluating its information technology platform and one requirement  of any new IHS system will be to enhance interoperability with VA,  pending the funding to do so. IHS also reported that the agency will  consider health information exchange participation as part of the agency’s  information technology modernization efforts.

Staff turnover. Officials from 9 of 15 facilities identified staff turnover at  VA, IHS, and THP facilities as an impediment to having better or  consistent coordination. VA, IHS, and THP facility officials described  situations in which the coordination between facilities was dependent on  specific staff or facility leadership. According to officials, when there was  turnover among these staff or positions went unfilled, or were eliminated,  the coordination decreased or came to a halt. For example, officials at  one VA facility said that they have found that if a sitting tribal government  expresses interest in VA collaboration, they have to act quickly and work  with the tribe before there is turnover and new tribal leadership comes in  with different priorities. Additionally, officials from one IHS facility  described a situation in which they had previously coordinated with their  local VA facility through that facility’s AI/AN liaison. However, the  coordination lapsed when the liaison left VA and the position went  unfilled. Similarly, a THP official stated that coordination with VA was  previously led by a nurse case manager on site who was a joint VA and  THP employee. The official said that since that person’s retirement, she  did not know who to contact at VA to coordinate veterans’ care.

Officials at one IHS facility noted that due to turnover and attrition they  would like to see more education for front line staff at both IHS and VA,  so they can more efficiently obtain care for patients at the VA. VA  headquarters officials acknowledged that staff turnover and retraining is a  challenge that they will need to continually address as the MOU is carried  out. In our prior work related to IHS and VA, we have found that both  agencies face challenges related to staff turnover and training.

VA Co-Payments. Officials at 3 of the 11 IHS and THP facilities we  contacted, as well as IHS headquarters officials and representatives of  two national tribal organizations said that the copayments that VA  charges veterans represented a barrier to AI/AN veterans receiving care.  While AI/AN veterans do not have any cost-sharing for care provided at  IHS or THP facilities, they are subject to the same copayments as other  veterans when they receive care from VA facilities. VA data shows, for  example, that of the 80,507 VA-enrolled self-identified AI/AN veterans in  in fiscal year 2017, about 30 percent were charged copayments,  averaging about $281.56 billed per veteran. Officials from one THP noted  that this kind of financial liability may discourage AI/AN veterans from  getting care at VA, or lead them to return to the THP after they realize  they will have to pay for care at VA.

While some of our interviewees suggested that VA should waive  copayments for AI/AN veterans, a VA official said they do not have the  legal authority to do this. The official said that their statute specifies the  categories of veterans for which they must charge copayments and VA is  not authorized to waive the copayments for AI/AN veterans on the basis  of their AI/AN status without statutory exemptions. While certain AI/AN  veterans may qualify for waived copayments based on their inclusion in  other statutory categories, AI/AN veterans are not specifically listed as a  category for which copayments can otherwise be waived. VA officials  also cautioned that because AI/AN veterans may qualify for waived  copayments through these other categories, the possibility of copays  should not discourage IHS or THP facilities from referring AI/AN veterans  to VA.

Since 2014, VA and IHS have continued to work together to oversee and  implement their MOU aimed at improving the health care provided to  dually eligible AI/AN veterans. While the agencies have made progress in  certain areas of the MOU, especially those related to reimbursement,  other parts have seen less attention. VA and IHS are now updating the  MOU, and plan to revisit the related performance measures. This gives  the agencies an opportunity to evaluate how well their existing oversight  mechanisms have been working, and to improve these mechanisms  accordingly in the future. Regardless of these updates, the agencies need  to have effective performance measures. While the agencies took steps  to improve MOU performance measures in response to one of our prior  reports, these steps were not sufficient and the measures they set lack  important attributes, including measurable targets. VA and IHS have  indicated that they plan to reevaluate performance measures as they  update the MOU, but have not indicated that these new measures will  identify targets. Absent targets, VA and IHS are limited in their ability to  measure progress towards MOU goals and ultimately make strategic  decisions about how and where improvements should be made.

At the local level, care for AI/AN veterans relies on coordination among  individual VA, IHS, and THP facilities. However, variations in relationships  among these many facilities and staff turnover creates challenges, which  heightens the importance of clear and consistent guidance from the  national level. Yet no written guidance exists related to referring AI/AN  veterans to VA facilities for specialty care. Without such guidance, VA  and IHS cannot ensure that facilities have a consistent understanding of  the available referral options for AI/AN veterans. Enhancing their  guidance in this area will help VA and IHS ensure that AI/AN veterans  have access to needed care.

We are making a total of three recommendations, including two to VA and  one to IHS. Specifically:

As VA and IHS revise the MOU and related performance measures,  the Secretary of Veterans Affairs should ensure these measures are  consistent with the key attributes of successful performance  measures, including having measurable targets. (Recommendation 1)

The Secretary of Veterans Affairs should, in consultation with IHS and  tribes, establish and distribute a written policy or guidance on how  referrals from IHS and THP facilities to VA facilities for specialty care  can be managed. (Recommendation 2)

As VA and IHS revise the MOU and related performance measures,  the Director of IHS should ensure these measures are consistent with  the key attributes of successful performance measures, including  having measurable targets. (Recommendation 3)

We provided a draft of this report to VA and the Department of Health and  Human Services for review and comment. We have reprinted the  comments from VA in appendix I and the comments from the Department  of Health and Human Services in appendix II. Both departments  concurred with our recommendations. The Department of Health and  Human Services also provided technical comments, which we  incorporated as appropriate.

In response to our recommendations to ensure revised performance  measures include key attributes of successful performance measures, VA  and the Department of Health and Human Services provided information  about the process for finalizing the new MOU, including conducting tribal  consultation. They noted that VA and IHS will work together to ensure  that performance measures under the new MOU include appropriate  measurable targets.

Regarding our recommendation to VA about establishing and distributing  a written policy or guidance on how referrals from IHS and THP facilities  to VA facilities for specialty care can be managed, VA noted the Office of  Community Care is working on a process to enhance care coordination  among all VA and non-VA providers—including IHS and THP providers.  VA noted that for IHS and THPs, this will include establishing forms and  procedures to refer patients to VA for specialty care, and that VA will  provide training to applicable staff once the process and procedures are  finalized. VA also noted that it is in the process of establishing an  advisory group that will include tribal, IHS, and VA representation, and will  make recommendations related to care coordination guidance and  policies. The target completion date for establishing this group is spring  2020.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  Secretaries of VA and the Department of Health and Human Services,  and other interested parties. In addition, the report will be available at no  charge on GAO’s website at http://www.gao.gov/.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or farbj@gao.gov. Contact points for our Office of  Congressional Relations and Office of Public Affairs can be found on the  last page of this report. Other major contributors to this report are listed in  appendix III.

Appendix I: Comments from the Department of Veterans Affairs

Appendix II: Comments from the Department of Health and Human Services

Appendix III: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Kathleen M. King (Director),  William Hadley (Assistant Director), Christina Ritchie (Analyst-in-Charge),  Jennie Apter, Shaunessye D. Curry, Jacquelyn Hamilton, and Vikki Porter  made key contributions to this report.

American Indians and Alaska Natives serve in the military at a higher rate than members of other racial groups, but are more likely to lack health insurance or have a related disability.

Some of these veterans are eligible to receive health care from both VA and the Indian Health Service, so these agencies agreed in 2010 to coordinate and share resources. VA also agreed to reimburse IHS and certain tribes providing direct care to these veterans.

We found that VA's reimbursements increased by 74% between FYs 2014-2018. We also found that VA and IHS could more effectively collaborate and measure program performance. We recommended they do so.