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

The JIF submission process encourages thoughtful planning and specific identification of resources necessary for success. The intra-and extra-organizational review process, as well as competitive national-level scoring, encourages thrift and innovation. Funded project proposals are generally compelling. Some JIF programs are constructed anew, combining space, bed capacity, and commitment with the requisite staffing, equipment, and team development to ensure safe startup. Examples include the neurosurgery and heart-lung-vascular programs. Others, like the orthopedics program, expand existing capabilities. In each instance, the new programs benefit all concerned: the federal taxpayer, each organization, and patients.

Outside Support and New Programs

The UC Davis Health System (UCDHS), through high-level education, training, and staffing, has explicitly supported these joint programs. Reliable, safe initiation, particularly for the cardiac and vascular programs, would not have been otherwise possible. Key staff members often hold academic faculty appointments, teach, write, and participate in UCDHS programs at all levels. Research in trauma care and other topics has also been facilitated. The positive relationship has supported joint program infrastructure, recruitment, and enhanced/maintained quality.

Multiple successful JIF collaborations and sharing projects, have generated a further, unforeseen benefit: The emergence of an intra-agency, financially relevant, federal market for innovative proposals. This has been coupled in the northern California setting with an emerging willingness by both organizations to potentially sustain a short-term loss for long-term financial or programmatic gain. Strict accounting between organizations, with real dollars going back and forth, has created pools of uncommitted profit, which organizational leaders can use to fund proposals not previously feasible given otherwise daunting fiscal constraints.

One recent example is a non-JIF program for patients requiring general surgery care. Under a no-load pilot program, some DoD surgeons work without additional compensation at VANCHCS facilities, and some general surgery operations are performed at DGMC. This serves to both maintain DoD practitioners’ clinical volume between deployments, and simultaneously address temporary VHA backlogs. Previous and current sharing agreement revenue, complemented by goodwill, supports the exchange. In this particular instance, previous JIF experience has cultivated innovation. Analysis and market discipline will determine its fate.

Limitations

Obstacles thwarting potential joint projects include inadequate projected case volume, logistical constraints, and inadequate ROI. Geographic challenges also limit collaboration in certain areas. The VANCHCS system covers 40,000 square miles. Emergency acute care for a patient mandates use of the nearest capable facility, often a local nonfederal facility. Inadequate communication between VHA and DoD EMR systems, exacerbated by privacy and security protections initiated by both organizations, also tends to block collaboration.

Notwithstanding the alignment over merger philosophy, merged information systems, or at least a faster, more reliable cross talk tool would certainly help. Bidirectional Healthcare Information Exchange (BHIE), if implemented more reliably, might still work. As a work-around, practitioners in joint programs usually practice with a VHA computer and a DoD computer side by side in order to obtain complete information for a given patient. Providers view this as ridiculous. However, all involved respect the need for intact DoD and VHA firewall/security systems.

These collaborative ventures have been created in a unique budgetary environment. Wars end. Congress adjusts budgets. Health care systems change. One or the other partner periodically experiences serious budgetary stress. However, the back-and-forth revenue streams described here tend to smooth the transitions. Despite budgetary and programmatic stress, we are maintaining/expanding all of the joint programs described herein. These programs deliver sustained, cost-effective care with improved access for veterans and military beneficiaries alike and continue to do so through planned, mutually aligned effort, not merger.

Acknowledgements
Current and former commanders of the 60th Medical Group at DGMC: Col Rawson Wood (current commander); Col Kevin Connelly, MD ; Col Brian Hayes, MD; Col Lee Payne, MD.

Current and former directors of VANCHCS: David Stockwell (current director); Brian O’Neill, MD; Lawrence Sandler; Lucille Swanson. UC Davis: Kenneth W. Kizer, MD, MPH, The Institute for Population Health Improvement, and The Center for Veterans and Military Health.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

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