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STATEMENT OF DR DAVID S. CHU UNDERSECRETARY OF DEFENSE (PERSONNEL AND
READINESS) COMMITTEE ON ARMED SERVICES SUBCOMMITTEE ON MILITARY PERSONNEL AND THE COMMITTEE ON VETERANS’ AFFAIRS SUBCOMMITTEE ON HEALTH
Mr. Chairman, I am pleased to present to you and the members of the Subcommittee the Department of Defense’s strategic vision and objectives for improving the partnership between the Department of Defense (DoD) and the Department of Veterans Affairs (VA). DoD places enormous value on its relationship with the VA. Since the outset of the sharing program which was established under the 1982 legislation, “Department of Veterans Affairs and Department of Defense Health Resources Sharing and Emergency Operations Act (38 USC 811(f)), DoD has subscribed to the promise for improved service to our personnel and economies of operation that health resources sharing has held. Resource sharing between VA and DoD facilities over the intervening years has resulted in the growth of sharing from a few agreements in the early years to over 600 sharing agreements in place today. However, many of these argeements are not fully utilized or active. While DoD’s collaboration with the VA dates back many years and much has been accomplished, it is time to reinvigorate these collaborative efforts to maximize sharing of health resources, to increase efficiency, and to improve care for the beneficiaries of both departments. The focus of our efforts is to move the relationship with the VA from one of sharing to a proactive partnership that meets the missions of both agencies while benefiting the servicemember, veteran and taxpayer. As I travel around the country meeting with our service men and women, I am also visiting our joint ventures, the VA Medical Centers (VAMCs) that are co-located with our bases, and potential areas of future collaboration with the VA. In December, I visited Tripler Army Medical Center where the DoD/VA cooperation has reached an advanced stage, with Tripler providing over $14 million a year in care to VA patients, with a variety of staff and service sharing agreements in place or planned. In January I visited San Diego Naval Medicine Center; as you know, in Southern California VA facilities are part of our TRICARE network of providers. In February, I visited the VAMC in Denver, Colorado, where they are discussing a new joint construction model with the University of Colorado. Last week, I visited Travis Air Force Base where a new VA clinic has just been opened next to the Air Force hospital. I also visited our joint venture at Nellis Air Force Base where the Air Force and VA jointly run an inpatient facility, maximizing their resources to provide the full range of health care services to VA and DoD beneficiaries. Looking toward the future, I just visited the Naval Hospital Great Lakes and the North Chicago VA Medical Center, where DoD and VA are proactively examining options for a joint health care operation in the future. While I believe there is still more work to do, I have seen more activity in the field between DoD and VA than I believe our data systems report. On February 11th, Dr. MacKay and I held a meeting bringing together our top health care and benefits experts at DoD and VA to discuss how we can together build a more collaborative relationship. We already have a number of initiatives working through our VA/DoD Executive Council, co-chaired by our Assistant Secretary of Health Affairs, Dr. Winkenwerder, and the Acting VA Under Secretary for Health, Dr. Murphy. This council provides the forum for senior health care leaders, including our Surgeons General, to proactively address potential areas for further collaboration, and resolve obstacles to sharing. We are building on the success of our health care council through the newly established VA/DoD Benefits Council, which is examining ways to expand and improve information sharing, refining the process of records retrieval and identifying procedures to improve the benefits claims process. We will be meeting with the co-chairs of these councils on a quarterly basis to demonstrate our commitment to ensuring they are successful in improving inter-departmental cooperation at all levels. Concurrent with these ongoing efforts, DoD is actively supporting the President’s Task Force to Improve Health Care Delivery to Veterans, announced by President Bush on Memorial Day 2001. DoD has provided office space, administrative support and functional experts to ensure the Task Force accomplishes its mission of improving coordination of health care for veterans and military retirees. I will continue to work closely with my colleague, Dr. Gail Wilensky, to ensure the success of the Task Force in meeting their objectives. Joint Use of DVA/DoD Facilities and Services A most visible example of Department of Veterans Affairs and Department of Defense partnerships has been the joint venture construction and operation of health care facilities. At present, there are seven joint ventures – eight, if you count a VA clinic sited at Fort Sill, Oklahoma next to the Army Hospital. At Albuquerque, New Mexico, the oldest joint venture between the Air Force and VA is now more than 14 years old. The other joint ventures vary in age and are located across the nation at Key West, Florida, El Paso, Texas, Las Vegas, Nevada, Fairfield, California, Anchorage, Alaska and Honolulu, Hawaii. Each joint venture is unique and complex. But if Albuquerque is any example, they are durable and provide great access and health care to the beneficiaries of both departments. The joint ventures have typically resulted from both agencies coordinating their health care needs and integrating their requirements in well planned out economically justified joint operations. I believe that we should interface our health care planning and jointly assess our future construction needs and, where possible, satisfy those needs through joint venture operations. In other examples of our partnering, we have taken advantage of changes in medical facility size requirements to provide greater access and cost-effective use of facilities. An example is the VA Medical Center in Nashville, Tennessee, and Blanchfield Army Hospital at Fort Campbell, Kentucky. These two facilities have a barter agreement. Nashville leases space for outpatient services for veterans. Blanchfield provides laboratory and radiology services for veterans. VA provides internal medicine physician services. Pharmaceuticals are exchanged on a per drug basis. Nashville is negotiating with the Army for VA to establish a Community-Based Outpatient Clinic. VA would provide physicians for specialty clinics in such areas as cardiology, pulmonology, internal medicine, oncology and infectious diseases. Fort Campbell is approximately 65 miles from the Nashville VA Medical and 100 miles from the Murfreesboro, Tennessee, VA Medical Center. Another example is at Louisville, Kentucky, where the VA Medical Center enhances the capabilities of the Ireland Army Hospital at Fort Knox, Kentucky, by providing staffing for Ireland’s primary care clinics, fully staffing the TRICARE primary care clinics and supporting numerous other MTF clinics and services including outpatient mental health, well women’s clinic, podiatry, urology, internal medicine, audiology, orthopedics, orthotics, radiology, prenatal nurse educator, oncology nurse case manager and various other administrative services. VA maintains a Community-Based Outpatient Clinic at Ireland. Inpatient and outpatient referrals are made to Louisville 40 miles away. Education and Training In the areas of education and training support, we share 320 VA/DoD agreements, including training for physicians and nurses. These agreements typically involve training opportunities in exchange for staffing assistance. Most agreements are between VAMCs and reserve units. Under a typical agreement, a VAMC provides space for weekend training drills, and, in return, the medical center receives staffing support. For example, the Tucson, Arizona, VA Medical Center trains nurses, technicians and dietitians of the 162nd Medical Squadron, Arizona National Guard, Tucson. In another agreement, the VA provides training for hospital corpsmen for the Naval Reserve and Marine Corps Reserve Center, Tucson. The medical center has similar agreements with six other reserve units in the area. The communities benefit from the close relationships that develop as a result of these agreements. A large number of VAMCs have agreements involving five or more reserve units. This joint training occurs in areas that truly have contemporary relevance including shock trauma, aeromedical evacuation, disaster preparedness, surgery, psychiatry, and pathology. Medical Research VA/DoD collaboration in medical research is widely known, especially in the area of post-traumatic stress disorder, infectious diseases, traumatic brain injury and spinal cord injury. This past year, research projects were selected based on merit, scientific review and relevance to the health concerns of veterans and military members. Areas of research include an epidemiological study of Amyotrophic Lateral Sclerosis (ALS) among Gulf War veterans and two clinical treatment trials of chronic health problems among veterans of the Gulf War. The VA and DoD recently completed research and development of an evidence-based clinical practice guideline for treatment of post-deployment health concerns. The guideline will be implemented system-wide in early 2002. Two protocols aimed at improving health risk communication of military unique risk factors among veterans have been funded by the Centers for Disease Control and Prevention (CDC) with data collection to begin in 2002. DoD Vision and Priorities for 2002 Our vision of DoD/VA coordination is a mutually beneficial partnership that optimizes the use of resources and infrastructure to improve access to quality health care and increase the cost effectiveness of each department’s operations while respecting the unique missions of the VA and DoD medical departments. Our guiding principles include collaboration, not integration; providing the best value for the taxpayer; establishment of clear policies and guidelines for DoD/VA partnering; and fostering innovative, creative arrangements between DoD and VA. As DoD moves toward a more proactive partnership with the VA, we have established short-term goals to be accomplished during this fiscal year. These include establishing solid business procedures for reimbursement of services, improving access to health care through VA participation in TRICARE, examining opportunities in pharmaceuticals, facilitating health care information exchange between the departments, and establishing a long-range joint strategic planning activity between DoD and VA. Standardized Reimbursement Procedures During the 1990s, flexibility was given to VA and DoD to establish locally developed rates for medical sharing agreements. This has resulted in the creation of multiple reimbursement rate structures across the country. The variability in payment structure makes the administration of the billing and collection process more difficult. Establishing standardized reimbursement procedures for sharing agreements between medical facilities will eliminate a significant barrier to increased resource sharing between the two departments. In July 2001, The VA/DoD Executive Council charged the Financial Management Work Group to develop recommendations for reimbursement policies and practices and streamlining financial processes between the departments. The Work Group is currently focusing on the development of a standardized reimbursement rate that would allow VA and DoD to exchange health care services without having to negotiate individual local rates. Currently, the Work Group is analyzing the appropriate discount rate to apply in order to provide the right incentives to both sellers and buyers of services. Planned implementation for a national rate is scheduled for October 1, 2002. Improving Access Through VA Participation in TRICARE The VA and the DoD operate the two largest Federal health care systems with a combined number of beneficiaries in both Departments exceeding 12 million. Opportunities exist to improve access to needed health care services by partnering with all VA facilities in the TRICARE provider networks. In 1995, the VA and DoD signed a Memorandum of Understanding (MOU) to allow the TRICARE managed care support contractor to consider Department of Veterans’ Affairs Health Care Facilities (DVAHCF) for participation in the contractor’s network.. The VA facility and providers must meet the TRICARE contractor requirements to participate as a TRICARE service provider. Since the signing of the MOU, efforts have been under way by the Managed Care Support Contractors to enhance their provider networks by signing up the VA facilities. To date approximately 80 % of VA facilities have agreements to be network providers; however, the use by the TRICARE contractors is limited. These agreements complement the existing specialty network and primary care availability in the TRICARE Prime service areas throughout the country. Our Managed Care Support Contractors have targeted VA facilities throughout the country to enter the TRICARE network. In Region 6, the managed care support contractor has had discussions with the Houston VA Medical Center to re-enter the TRICARE network. In the Central Region, they have moved to the next phase of their partnership strategy by creating a Central Region Federal Health Care Alliance. The critical focus is on fostering collaboration between the DoD and the VA. The Central Region Federal Health Care Alliance is a collaboration among the TRICARE Central Lead Agent Office, the military treatment facilities, TriWest Healthcare Alliance’s commercial network, and the VA to provide a coordinated approach to providing quality health care in the most effective and efficient manner. The initial project is targeting the states of North Dakota, South Dakota, and Minnesota. Humana is also entering discussions with the North Chicago VA Medical Center. The enhanced effort to integrate the VA into the Managed Care Support Contractor’s networks will improve access to specialty and primary care services that are not currently available in certain sections of the United States. A partnership with the VA for 100% of facility participation in the TRICARE networks will maximize the capabilities of both federal agencies and fully utilize the federal health care services. As DoD moves toward the next generation of TRICARE contracts, we have active VA participation in the formulation of policies and procedures governing our partnership. Pharmaceuticals We continue to experience remarkable success in our joint pharmaceutical-related efforts. Progress is being made to enable DoD to use the VA Consolidated Mail Order Pharmacy later this year. DoD is also discussing VA participation in the Pharmacy Data Transaction Service (PDTS), which allows DoD to build a patient medication profile for all beneficiaries regardless of the point of service. Since its full implementation, PDTS has identified over 20,000 life threatening interactions resulting from beneficiaries using more than one pharmacy for prescription service. We feel that VA could truly benefit from this system. Also, our joint DoD/VA contracting for pharmaceuticals is really paying off. VA and DoD have joint national pharmaceutical contracts which are developed through the collaborative efforts of the VA National Acquisition Center (NAC), the VA Pharmacy Benefits Management (PBM) Strategic Health Group, the Defense Supply Center Philadelphia (DSCP) and the DoD Pharmacoeconomic Center (PEC). To date, the VA and DoD have jointly awarded 57 joint pharmaceutical contracts with a projected annual cost avoidance in excess of $100 million. Facilitating Health Care Information Exchange DoD strongly supports the need for appropriate sharing of electronic health information across federal agencies. This is particularly true with the VA to ensure they have the information necessary to make determination of benefit decisions and to ensure the continuity of care of eligible veterans. The Federal Health Information Exchange, formerly known as the Government Computer-based Patient Record (GCPR), is a collaborative effort among DoD, VA and the Indian Health Service. The Near Term solution, which is now being tested, will enable DoD to send laboratory results, radiology results, outpatient pharmacy, and patient demographic information on separated Service members to the VA. Before FY 2005, we expect that the patient record information will flow not only to VA, but also from VA to DoD. This disclosure of protected health information to the VA will be compliant with the Privacy Act and the Health and Human Services regulations on Standards for Privacy of Individually Identifiable Health Information under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The IM/IT Work Group under the VA/DoD Executive Council is currently coordinating a Memorandum of Agreement that will institutionalize this data exchange between the two Departments. An assessment of requirements for additional data is underway. We are also working with VA to determine and enhance the degree of compatibility in information assurance policies and guidance and data architecture standards. Our work has already revealed that we have a number of standards in common. In addition, we are developing and testing an interface for electronic transfer of reference laboratory data between our respective health information systems and commercial laboratories to replace current manual methods. We have joined in medical automation research in the Defense Information Research Center. We have linked DoD's Composite Health Care System and VA's Veterans Information Systems and Technology Architecture (VISTA), successfully tested clinical laboratory data exchange, and accelerated evaluation of off-the-shelf software in the automation of patient records. Sharing information about our patients, particularly when our two agencies may treat the same patient, is vital to ensure continuity of care. DoD and VA continue to work on the sharing of information contained in each agency’s health care information system. For example, we are actively exploring opportunities for sharing our enrollment database (DEERS) with the VA through our VA/DoD Benefits Council. Establishing a Long-Range DoD/VA Strategic Plan Since 1982, the two Departments have worked hard to generate increases in sharing and associated cost savings. The partnership has weathered several rounds of military hospital closures, and a dynamic and fluid health care environment. We have been successful by looking toward the future, not the past. In that regard, DoD believes there could be more opportunity for partnering through a strategic planning process that would allow the two Departments to identify for themselves the opportunities for greater coordination and collaboration. Through the VA/DoD Executive Council, DoD will propose the establishment of a Joint Strategic Planning Committee to report directly to the Co-Chairs of the VA/DoD Executive Council. This committee would be charged with developing a long-range strategic planning document for 2003-2009. The strategic planning effort will encompass health care resources, capital assets, contingency roles and IM/IT opportunities. We also look forward to participating in the VA's Capital Asset Realignment for Enhanced Services (CARES) study in an effort to jointly examine opportunities for future health care collaboration. Future Challenges and Opportunities While the advantages of our sharing agreements, joint facility utilization and clinical collaboration are apparent, the evolving environment of federal health care and recent changes in policy and benefits call for continuing reassessment of opportunities that are mutually beneficial for our systems. As we work toward a closer partnership with VA, we must continue to address the ongoing challenges of different, but not mutually exclusive, missions, populations and cultures. As an example, the VA population is a far older group, often with chronic conditions. In contrast, more than half of DoD’s eight million beneficiaries are age 44 or younger, and 50% of our beneficiaries are female compared to 5% of the VA population. The DoD’s military treatment facilities are constantly involved in wartime readiness and training activities. As we continue to respond to the ever-changing health care environment, the DoD leadership recognizes that it must develop creative approaches to health care delivery while retaining the flexibility to respond to the demands of our dual mission of operational and everyday medicine. Conclusion Mr. Chairman, my VA colleague, Dr. MacKay, and I, share a common vision of quality health care for our men and women serving our country, their families, and those that have served us so well in the past. DoD’s concern for the well-being of our servicemembers extends beyond just their time on active duty. Cooperative efforts with the VA will provide the best possible service through new initiatives and increased efficiency to the benefit of the servicemembers, veterans and taxpayers. Back to Witness List |