Clinical Review
Outreach to Women Veterans of Iraq and Afghanistan: A VA and National Guard Collaboration
Women in the military have served in the Iraq War (Operation Iraqi Freedom [OIF]) and are serving in the Afghanistan war (Operation Enduring...
The VA and the DoD operate completely independent health care systems. Integrated provision of health care for the populations served is a compellingly attractive goal given the obvious overlaps, but has proven deceptively difficult to implement.
Despite efforts begun in 1998 to accomplish a reliable, comprehensive, bidirectional exchange of patient-specific health care information between systems, 16 years later this has yet to be reliably available. In most locales, VHA practitioners cannot easily access details of the medical care provided to DoD personnel. Attempts to merge the 2 electronic medical record (EMR) systems have also been fraught with difficulty.1 Even at the new, joint VHA/DoD Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois (which opened in October 2010 to serve a mix of active-duty servicemen, TRICARE beneficiaries, and VA enrollees under a single roof), care using a single EMR system has not been possible.
The Institute of Medicine, in an invited review, has specifically criticized the unsatisfactory, piecemeal EMR integration.2 On February 5, 2013, the Secretary of the VA and the Secretary of Defense formally abandoned efforts to construct a single VA/DoD integrated EMR system by 2017. Instead, both organizations would, in then Secretary of Defense Leon Panetta’s words, “…focus our immediate efforts on integrating VA and DoD health data as quickly as possible, by focusing on interoperability and using existing solutions.”3
Joint VA/DoD health care programs in Northern California have abandoned merged structures in favor of mutual alignment. The practical value of aligning care systems is to extract benefit from structured, economically rational, win-win collaborations, as opposed to the forced merger approach. Mutual alignment generates relatively prompt, reliable results, to the benefit of all concerned.
Related: Developing Joint VA and DoD Health Programs
This report details a consistently favorable experience with this philosophy, which has considerable relevance as federal and nonfederal systems explore future joint ventures. Specifically, this report describes the substantial multiyear savings from a combination of various DoD/VA Joint Incentive Fund (JIF) and Sharing Agreement projects conducted by the VA Northern California Health Care System (VANCHCS) and the U.S. Air Force (USAF) 60th Medical Group’s (60MDG’s) David Grant Medical Center (DGMC).
Background and Methods
VA Northern California Health Care System currently serves 92,000 unique veteran patients in a service area of 40,000 square miles through a network of facilities and clinics at 9 sites across northern California. Rapid year-over-year growth of VANCHCS continues, and in fiscal year (FY) 2013, so-called unique enrolled veterans increased by 4.7%. David Grant Medical Center is a 116-bed DoD flagship hospital at Travis Air Force Base in Fairfield, California, which is home to the 60MDG. In 2013, VANCHCS and DGMC celebrated the 20th year of collaborative projects.
Congressional mandates encompassed in sections 101, 1701, 1782, 1783, and 8111 of Title 38, United States Code, as well as sections 1074, 1079, 1086, 1104, and Chapter 61 of Title 10, United States Code, have been addressed through a variety of DoD and VA Health Care Resource Sharing Program directives. The most recent instruction covering these agreements was reissued on January 23, 2012 (DoD instruction 6010.23). Sharing Agreements and joint ventures are permitted when such arrangements “…will improve access to quality health care or increase cost-effectiveness of the health care provided … to beneficiaries of both departments.” A Joint Executive Council (JEC), co-chaired by the VA Deputy Secretary and the DoD Acting Under Secretary of Defense for Personnel and Readiness, oversees joint VA/DoD activities.
The collaborative initiatives described in this article have all blossomed into sustainable, ongoing, valuable programs. Aided by JIF grants, they transitioned to standard VHA and DoD budgetary mechanisms in the third year of operation. For the VHA, such ongoing funding is accomplished through the Veterans Equitable Resource Allocation (VERA) budgeting system. Despite overall national/regional advantages, this funding model can result in substantial fiscal pressure for rapidly growing VHA systems, such as VANCHCS. DoD facilities and deployable operational teams, such as the 60MDG, are funded through separate DoD mechanisms. TRICARE services are funded through an entirely different budget. The complexities of this process preclude easy summary in this paper.
Recognizing that new collaborative initiatives inevitably add fiscal stress to involved facilities, the JEC has periodically offered 2-year competitive grant funding on a national basis to support winning proposals. Such JIF grants offer financial support to initiate potentially value-added collaborations. The VHA and DoD equally fund the annual award pool for these JIF grants. In response to periodic solicitations, VHA facilities team with DoD partners to jointly submit concept proposals.