VA and Indian Health Service: Actions Needed to Strengthen Oversight and Coordination of Health Care for American Indian and Alaska Native Veterans
Fast Facts
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.
Cherokee Warrior Memorial, Cherokee Nation, Tahlequah, Oklahoma
The granite Cherokee Warrior Memorial is dedicated to Cherokee Nation veterans, living and dead.
Highlights
What GAO Found
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.
Amount of VA Reimbursed Claims, Fiscal Years 2014 through 2018
|
|
2014 |
2015 |
2016 |
2017 |
2018a |
|
Indian Health Service facilities (in millions) |
$7.2 |
$7.8 |
$7.2 |
$6.2 |
$8.0 |
|
Tribal Health Program facilities (in millions) |
$4.3 |
$8.3 |
$10.4 |
$10.8 |
$12.1 |
Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-19-291
aFacilities have 12 months from the date of service to file claims for VA reimbursement. Therefore, fiscal year 2018 totals could increase. The fiscal year 2018 data were current as of Sept. 30, 2018.
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.
Why GAO Did This Study
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.
Recommendations
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.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | 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) |
VA concurred with this recommendation. In February 2022, VA reported that a new MOU between VA and IHS was signed October 1, 2021. VA noted that a related, draft operational plan was completed on January 30, 2022, and was under review by IHS and VA's Veterans Health Administration (VHA), with a focus on performance targets and measures. In December 2022, VA reported that the MOU Operational Plan had been completed and tribal consultations were held September through October 2022. Since that time, VA has provided updates on progress towards establishing new MOU-related performance measures. In February 2024, VA provided documentation showing that a MOU Data & Metric Workgroup had developed some MOU-related performance measures and begun collecting some initial data. However, additional work remained, including establishing numerical targets for the measures as well as determining data collection and reporting time frames. In August 2024, VA told us that as of May 2024, oversight of the MOU had been moved from the VHA Office of Rural Health to the VHA Office of Tribal Health, and that as such, the office was taking the opportunity to review the MOU, the Operational Plan, and current performance measures. VA noted that in the wake of this organizational realignment, the Office of Tribal Health would be critically reviewing the establishment of appropriate mutual MOU performance measures and measurable targets for FY 2025. Therefore, the agency noted that VHA was extending the target completion date for this work until April 2025. As such, the recommendation remains open, and we will continue to monitor VA's and IHS's progress towards implementing measurable targets for the MOU's performance measures.
|
| Department of Veterans Affairs | 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 Tribal Health Program (THP) facilities to VA facilities for specialty care can be managed. (Recommendation 2) |
VA concurred with our recommendation. In June 2021, VA reported that the agency had consulted with IHS and THPs to establish and distribute a standardized approach to care coordination, including a process on how referrals from IHS and THP facilities to VA facilities can be managed. The Care Coordination Approach was completed and cleared by the Veterans Health Administration in January 2021. The new process outlined in the Care Coordination Approach document creates a standardized approach for managing requests to VA from IHS and THP providers. This should help eliminate confusion about the process for referring AI/AN veterans from IHS or THP facilities to VA, and ultimately improve AI/AN veterans access to care. As such, we are closing this recommendation as implemented.
|
| Indian Health Service | 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) |
IHS concurred with this recommendation. In December 2021, IHS reported that effective, October 1, 2021, VA and IHS executed a new MOU. The agency reported that IHS and VA will continue working together to develop an annual operation plan to ensure that performance measures include appropriate measurable targets. In February 2022, VA reported that that the draft operational plan was completed on January 30, 2022, and was under review by IHS and VA's Veterans Health Administration (VHA), with a focus on performance targets and measures. In December 2022, IHS reported that the MOU Operational Plan had been completed and tribal consultations were held September through October 2022. Since that time, VA has provided updates on progress towards establishing new MOU-related performance measures. In February 2024, VA provided documentation showing that a MOU Data & Metric Workgroup had developed some MOU-related performance measures and begun collecting some initial data. However, additional work remained, including establishing numerical targets for the measures as well as determining data collection and reporting time frames. In August 2024, VA told us that as of May 2024, oversight of the MOU had been moved from the VHA Office of Rural Health to the VHA Office of Tribal Health, and that as such, the office was taking the opportunity to review the MOU, the Operational Plan, and current performance measures. VA noted that in the wake of this organizational realignment, the Office of Tribal Health would be critically reviewing the establishment of appropriate mutual MOU performance measures and measurable targets for FY 2025. Therefore, the agency noted that the target completion date for this work was being extended until April 2025. As such, the recommendation remains open, and we will continue to monitor VA's and IHS's progress towards implementing measurable targets for the MOU's performance measures.
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