Key Issues > VA and DOD Health Care Management
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VA and DOD Health Care Management

The Department of Veterans Affairs (VA) and the Department of Defense (DOD) have faced challenges with how they manage their health care programs—specifically with program administration, workforce issues, health information technology (IT), and health care resources.

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VA and DOD Health Care Program Administration

  • VA policies. To provide timely and high-quality health care to the nation’s veterans, VA needs to develop national policies and communicate and implement them throughout the department. For example, VA needs to clarify policy and guidance documents, ensure that staff have access to these documents, incorporate feedback from VA medical facilities into national policy, ensure that local and national policies are aligned, and establish a process to approve and track policy exemption waivers when VA medical facilities cannot meet certain policy requirements.
  • VA construction. VA has faced challenges in managing major medical facility construction projects—i.e., those costing more than $10 million. While VA has taken some actions to address these issues, VA still needs to improve its cost estimates and schedules for major construction projects to ensure they remain on schedule and within budget.
  • DOD health reform. The National Defense Authorization Act of 2017 required DOD’s Defense Health Agency to assume administrative responsibility of DOD’s military treatment facilities (MTF) from the military services, and to develop an implementation plan that eliminates duplicative activities and maximizes efficiency. DOD identified key steps in its June 2018 plan to improve the effectiveness and efficiency of the administration of MTFs, but additional actions are needed to address weaknesses in the plan. For example, the plan establishes a goal of reducing headquarters-level personnel by 10 percent, but does not provide specific details about how this will be achieved.

Health Care Workforce

  • VA physician staffing. VA knows the number of physicians its Veterans Health Administration (VHA) employs (over 11,000), but it lacks data on how many contract physicians and physician trainees (e.g., medical residents) VHA uses to meet its staffing needs. Moreover, VA uses multiple strategies to support the hiring and retention of physicians (such as financial incentives and a physician training program), but it has not evaluated the effectiveness of these strategies.
  • VA nurse recruitment and retention. VA faces challenges in recruiting and retaining an adequate and qualified nurse workforce to provide quality and timely care in VHA facilities—particularly for nurses with advanced professional skills, knowledge, and experience, which is critical given veterans' needs for more complex and specialized services. Although VA uses multiple strategies to support nurse recruitment and retention, it has not evaluated the collective effectiveness of these strategies.
  • VA human resources. VA needs to improve its capacity to ensure it is meeting staffing needs at its VHA facilities, and create more transparent employee rating and reward systems.

HR Challenges at the Department of Veterans Affairs’ Veterans Health Administration (VHA)

HR Challenges at the Department of Veterans Affairs

  • DOD military physician staffing. Because of nationwide shortages and other challenges, DOD offers programs and incentives to attract and retain more than 16,000 military physicians. However, DOD needs to develop coordinated strategies across the military services to alleviate physician gaps, improve tracking of medical student data, and develop a method to accurately determine medical education costs.

Number of Military Physician Specialties That Were Below Authorizations, Fiscal Year 2015

HR Challenges at the Department of Veterans Affairs

Health IT

  • VA and DOD interoperability. For two decades, VA and DOD have used a patchwork of initiatives to increase interoperability between their electronic health record systems. Since 2008, the DOD and VA Interagency Program Office has been involved in various approaches to increase health information interoperability between the two departments. VA has been planning to modernize its system, and has recently decided to adopt the same platform that DOD is currently implementing. VA is still early in its efforts to transition to the new platform, with most of the implementation occurring after 2019. VA needs to ensure that the role and responsibilities of the Interagency Program Office are clearly defined within the governance plans for acquisition of the department's new electronic health record system.

Timeline of Four Efforts to Modernize the Department of Veterans Affairs' Electronic Health Records System

Timeline of Four Efforts to Modernize the Department of Veterans Affairs' Electronic Health Records System

  • VA IT systems that support health care. While VA has established some recommended IT practices, it still needs to ensure that VA’s health care programs are supported by IT systems capable of delivering effective health care services.

Health Care Resources

  • VA clinical productivity. VA collects data on the productivity and efficiency of its health care providers and medical facilities. However, VA needs to establish a process for reviewing medical facilities’ plans for addressing low clinical productivity and inefficiency.
  • VA contracting. VA procures a wide range of goods and services, including medical supplies that are essential to meeting its mission to provide health care to veterans. VA needs to improve its procurement processes and achieve cost savings by complying with applicable policy and regulation to obtain available discounts when procuring medical supplies.
  • DOD improper payments. Improper payments—payments that were made in an incorrect amount or should not have been made at all—drive up health care costs. DOD uses a methodology for estimating TRICARE improper payments that is less comprehensive than the methodology used by Medicare. Specifically, DOD only examines the claims performance of the contractors that processed TRICARE claims and does not examine the medical record documentation to verify if sampled payments for services provided to beneficiaries were medically necessary and supported by documentation. While DOD has awarded a contract that will allow a more comprehensive improper payment measurement methodology using retrospective medical records reviews, DOD needs to fully implement the new methodology and identify the underlying causes of improper payments.
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