Mutual Alignment Trumps Merger for Joint VA/DoD Health Care Programs

Measuring Program Success

The funded and implemented JIF programs have all been successful, with positive ROI ranging from 10% to 284% (Table 1). Newer programs lacking a final closeout report are all on track for positive ROI. One additional JIF program, for a joint hematology-oncology center, was delayed by staffing challenges but has now commenced.

Over the past 7 years, outpatient volume and services provided by DGMC have increased. Outpatient support services provided by VANCHCS for DoD personnel at remote sites, while still substantial, diminished (Figures 1 and 2). Such changes reflect intentional concentration at DGMC. Also, a VHA pharmacy service provided to USAF personnel at a site distant from DGMC was intentionally downsized to embrace a mailed-medication program.

Inpatient hospital discharges for VHA enrollees and bed-days of care at DGMC have increased substantially (Figure 3). As a result of sharing programs and JIF programs, VHA enrollees currently account for about 40% of total hospital census at DGMC. About 108 professionals paid by VANCHCS currently work at DGMC. In most cases, as formalized in specific post-JIF sustainment agreements, VANCHCS is reimbursed for clinical staff salary and benefits if such staff are working at DGMC within a JIF program. For inpatient and procedural care, unless charges are specifically excluded as part of specific JIF agreements, VANCHCS pays DGMC at a rate of 75% of CMAC (ie, about 75% of Medicare rates) for every admission. Given geographic constraints, a VHA mandate to keep waits for specialty care under 14 days, and finite assistance levels from other VAMCs in VISN 21, a majority of these cases would otherwise be treated in community fee programs (at a higher cost of 100% of CMAC plus professional fees).

Volume has grown in all such programs (Table 2). Growth in the category of “open cardiac procedures,” however, has been intentionally limited by a VISN 21 requirement that care for VHA patients be provided only when existing VISN 21 cardiac programs cannot accommodate a particular case.

Since FY 2011, as a result of improved analytics, VANCHCS has been able to calculate its global savings (cost avoidance) stemming from all JIF and other sharing programs. Calculating the difference between community fee cost and DGMC cost as about 25% of CMAC (which offers a floor estimate of actual savings), these ongoing programs now save the VANCHCS $7.78 million per year (Table 3).

Positive overall federal ROI (ie, ROI from the taxpayer’s perspective), measured in dollars, is reported at the end of year 3 for every JIF-funded program. Substantial additional ROI could be captured by other metrics, such as timeliness of care and patient satisfaction, and would be favorable for all listed programs (data not shown).

Discussion

Had VANCHCS and DGMC attempted a merged information and management structure for the JIF programs, implementation would have been seriously delayed, if not entirely thwarted. Instead, by explicitly aligning efforts around each organization’s existing capabilities, assets and attributes, new valuable services were quickly developed. Patients now receive high-quality treatment in specialty areas not previously offered (and in some instances, not previously offered by either system).

As noted previously, the DoD and the VHA health care systems vary considerably. For DGMC and the 60MDG, during a time of war, optimal triage practices, safe/speedy transport, and the reliable delivery of appropriate trauma care for the injured warrior represent core missions. The VHA, on the other hand, is dedicated to the well-being, health, and lifetime medical-surgical care of enrolled veterans. The VHA population has relatively high numbers of elderly patients with serious chronic health conditions, such as heart disease, vascular disease, and cancer. VHA also provides subacute and rehabilitative care for younger veterans who served more recently in Iraq and Afghanistan. Overall, the VHA population stands quite distinct from that of our young active-duty forces and their dependents.

The VHA patient population (6.3 million patients receiving treatment and over 8.7 million enrolled) greatly exceeds that of the DoD. For this and other reasons, experience, current skills, and training differ considerably between VHA and DoD practitioners. For active-duty DoD practitioners, especially surgeons, the JIF projects provide avenues for development/maintenance of skills. Further, the JIF-enabled influx of VHA personnel at DGMC enhances staffing at DGMC, thereby improving the capacity of DGMC and the 60MDG’s potential surge capacity. Finally, ongoing joint programs have fostered provider relationships, academic opportunities, and training for DoD personnel between deployments.

The effort also helps personnel satisfy new, quantitative, procedural volume standards (aka currency standards) for DoD/USAF surgeons. For VANCHCS, which is seriously pressed for acute inpatient capacity, the DGMC facility space and beds supporting the joint programs represent an attractive alternative to other options, such as new hospital construction, distant transfers, or reliance on community care (Table 4).