VA and IHS:

Further Action Needed to Collaborate on Providing Health Care to Native American Veterans

GAO-13-354: Published: Apr 26, 2013. Publicly Released: Apr 26, 2013.

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Randall B. Williamson
(202) 512-7114
williamsonr@gao.gov

 

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What GAO Found

The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) have developed mechanisms to implement and monitor their memorandum of understanding (MOU); however, the performance metrics developed to assess its implementation do not adequately measure progress made toward its goals. VA and IHS have defined common goals for implementing the MOU and developed strategies to achieve them. They have also created two mechanisms to implement the MOU--12 workgroups with members from both agencies to address the goals of the MOU, and a Joint Implementation Task Force, comprised of VA and IHS officials, to oversee the MOU's implementation. These steps are consistent with practices that GAO has found enhance and sustain agency collaboration. The agencies have also developed three metrics aimed at measuring progress toward the MOU's goals. However, two of the three metrics are inadequate because their connection to any specific MOU goal is not clear and, while they include quantitative measures that tally the number of programs and activities increased or enhanced as a result of the MOU, they lack qualitative measures that would allow the agencies to assess the degree to which the desired results are achieved. The weaknesses in these metrics could limit the ability of VA and IHS managers to gauge progress and make decisions about whether to expand or modify their programs and activities.

VA and IHS face unique challenges associated with consulting with a large number of diverse, sovereign tribes to implement the MOU, and lack fully effective processes to overcome these complexities. VA and IHS officials told us the large number (566 federally recognized tribes) and differing customs and policy-making structures present logistical challenges in widespread implementation of the MOU within tribal communities. They also told us that tribal sovereignty--tribes' inherent right to govern and protect the health, safety, and welfare of tribal members--adds further complexity because tribes may choose whether or not to participate in MOU-related activities. Consistent with internal controls, VA and IHS have processes in place to consult with tribes on MOU-related activities through written correspondence and in-person meetings. However, according to tribal stakeholders GAO spoke with, these processes are often ineffective and have not always met the needs of the tribes, and the agencies have acknowledged that effective consultation has been challenging. For example, one tribal community expressed concern that agency correspondence is not always timely because it is sent to tribal leaders who are sometimes not the tribal members designated to take action on health care matters. Similarly, some tribal stakeholders told GAO that the agencies have not been responsive to tribal input and that sometimes they simply inform tribes of steps they have taken without consulting them. VA and IHS have taken steps to improve consultation with tribes. For example, VA has established an Office of Tribal Government Relations, through which it is developing relationships with tribal leaders and other tribal stakeholders. Additionally, in Alaska, VA has been consulting with a tribal health organization for insight on reaching tribes. However, given the concerns raised by the tribal stakeholders GAO spoke with, further efforts may be needed to enhance tribal consultation to implement and achieve the goals of the MOU.

Why GAO Did This Study

Native Americans who have served in the military may be eligible for health care services from both VA and IHS. To enhance health care access and the quality of care provided to Native American veterans, in 2010, these two agencies renewed and revised an MOU designed to improve their coordination and resource sharing related to serving these veterans. GAO was asked to examine how the agencies have implemented the MOU.

This report examines: (1) the extent to which the agencies have established mechanisms through which the MOU can be implemented and monitored; and (2) key challenges the agencies face in implementing the MOU and the progress made in overcoming them. To conduct this work, GAO interviewed VA and IHS officials and reviewed agency documents and reports. GAO also obtained perspectives of tribal communities through attendance at two tribal conferences; interviews with tribal leaders and other tribal members, including veterans; and interviews with other stakeholders, such as health policy experts and consultants.

What GAO Recommends

GAO recommends that the agencies take steps to improve the performance metrics used to assess MOU implementation and to develop better processes to consult with tribes. VA and the Department of Health and Human Services agreed with these recommendations.

For more information, contact Randall Williamson at (202) 512-7114 or williamsonr@gao.gov.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: The Indian Health Service (IHS) in HHS and the Department of Veterans Affairs concurred with revised revised performance metrics for the Joint VA and IHS Memorandum of Understanding (MOU) on April 7, 2015 and August 24, 2015 respectively. In addition, all MOU Work Groups are required to use a specific template and make quarterly reports for these metrics. These metrics and the reporting template and mechanism were designed to be quantitative to allow decision makers determine whether MOU goals are being met.

    Recommendation: To ensure the health care needs of Native American veterans are addressed most efficiently and effectively, as the agencies move forward with revising the MOU's performance metrics and measuresthe Secretary of Veterans Affairs and Secretary of Health and Human Services should, ensure that the revised metrics and measures allow decision makers to gauge whether achievement of the metrics and measures supports attainment of MOU goals.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: The Indian Health Service (IHS) in HHS and the Department of Veterans Affairs concurred with revised revised performance metrics for the Joint VA and IHS Memorandum of Understanding (MOU) on April 7, 2015 and August 24, 2015 respectively. In addition, all MOU Work Groups are required to use a specific template and make quarterly reports for these metrics. These metrics and the reporting template and mechanism were designed to be quantitative to allow decision makers determine whether MOU goals are being met.

    Recommendation: To ensure the health care needs of Native American veterans are addressed most efficiently and effectively, as the agencies move forward with revising the MOU's performance metrics and measuresthe Secretary of Veterans Affairs and Secretary of Health and Human Services should, ensure that the revised metrics and measures allow decision makers to gauge whether achievement of the metrics and measures supports attainment of MOU goals.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: VA and IHS within HHS collaborated on addressing this recommendation which required VA to take steps in its approach to communicating with tribes about VA programs. VA's process for identifying the appropriate tribal members to communicate with about MOU-information involved obtaining recommendations from tribes during 2012 to develop a communications plan for the MOU. VA subsequently determined that the primary point of contact to formally convey MOU information will be the 566 tribal leaders. To contact these leaders VA reported that it uses the U.S. Department of the Interior, Bureau of Indian Affairs Tribal Leaders Directory which is published annually with an up-to-date listing of Federally recognized tribes. VA developed processes related to communicating with tribal communities and establishing timelines for releasing information through the issuance in February 20, 2015 of both a Handbook (?Consultation and communication with Federally-Recognized Indian Tribes?) and a related directive that establishes responsibilities, requirements and processes for engaging tribes in consultation, including the process for responding to tribal input and a process for establishing timelines for releasing information to tribal communities to ensure they have enough time to review and provide input. The Handbook identifies nine steps that VA employees must follow when conducting a tribal consultation process including: consultation should take place prior to any actions that may significantly affect tribal resources, rights or lands; tribal leaders are to be notified by formal letter, phone call or e-mail; and VA should provide the tribe at least 30-daynotice prior to a consultation meeting.

    Recommendation: To ensure the health care needs of Native American veterans are addressed most efficiently and effectively, the Secretary of Veterans Affairs and Secretary of Health and Human Services should develop processes to better ensure that consultation with tribes is effective, including the following, (1) a process to identify the appropriate tribal members with whom to communicate MOU-related information, which should include methods for keeping such identification up-to-date. (2) A process to clearly outline and communicate to tribal communities the agencies' response to tribal input, including any changes in policies and programs or other effects that result from incorporating tribal input. (3) A process to establish timelines for releasing information to tribal communities to ensure they have enough time to review and provide input or, in the case of meetings, determine the appropriate tribal member to attend the event.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: VA's process for identifying the appropriate tribal members to communicate with about MOU-information involved obtaining recommendations from tribes during 2012 to develop a communications plan for the MOU. VA subsequently determined that the primary point of contact to formally convey MOU information will be the 566 tribal leaders. To contact these leaders VA reported that it uses the U.S. Department of the Interior, Bureau of Indian Affairs Tribal Leaders Directory which is published annually with an up-to-date listing of Federally recognized tribes. VA developed processes related to communicating with tribal communities and establishing timelines for releasing information through the issuance in February 20, 2015 of both a Handbook (?Consultation and communication with Federally-Recognized Indian Tribes?) and a related directive that establishes responsibilities, requirements and processes for engaging tribes in consultation, including the process for responding to tribal input and a process for establishing timelines for releasing information to tribal communities to ensure they have enough time to review and provide input. The Handbook identifies nine steps that VA employees must follow when conducting a tribal consultation process including: consultation should take place prior to any actions that may significantly affect tribal resources, rights or lands; tribal leaders are to be notified by formal letter, phone call or e-mail; and VA should provide the tribe at least 30-daynotice prior to a consultation meeting.

    Recommendation: To ensure the health care needs of Native American veterans are addressed most efficiently and effectively, the Secretary of Veterans Affairs and Secretary of Health and Human Services should develop processes to better ensure that consultation with tribes is effective, including the following, (1) a process to identify the appropriate tribal members with whom to communicate MOU-related information, which should include methods for keeping such identification up-to-date. (2) A process to clearly outline and communicate to tribal communities the agencies' response to tribal input, including any changes in policies and programs or other effects that result from incorporating tribal input. (3) A process to establish timelines for releasing information to tribal communities to ensure they have enough time to review and provide input or, in the case of meetings, determine the appropriate tribal member to attend the event.

    Agency Affected: Department of Veterans Affairs

 

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