Evaluation of the Lovell Federal Health Care Center Merger Findings, Conclusions, and Recommendations (2012) / Chapter Skim
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3 Implementation
3 Implementation
Pages 47-102
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1 Initially, the proposed joint health care delivery initiative was called the federal health care facility, or FHCF. It began to be called a federal health care center in late 2007, in conjunction with plans to name the joint medical center after Captain James A
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and surgical facilities were upgraded by the VA. Phase 3 was the shift of all Navy outpatient services to the new ACC building and other renovated spaces on the west campus of the Lovell FHCC, as well as the implementation of the FHCC as a single organization under a single chain of command in 2010.
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Representative Mark Kirk announced that construction on a $170 million joint VA/Navy health care facility next to the NCVAMC would begin in about 5 years. He told veterans at a Veterans Day ceremony the same day that "if the Navy moves into this facility, it can never close." NCVAMC director Patrick Sullivan said that the expanded volume of Navy patients would lead to the addition of inpatient surgical services in 2005 (Susnjara, 2003)
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. In June 2006, after the ED, operating rooms, and intensive/critical care unit were upgraded, inpatient medical and surgical services for DoD beneficiaries were moved to the NCVAMC.
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Phase 3 On May 26, 2005, William Winkenwerder, the assistant secretary of defense for health affairs, and Jonathan Perlin, the under secretary of veterans affairs for health, the co-chairs of the HEC, signed an EDM that approved construction of a Navy-funded ACC adjoining the North Chicago VA medical center hospital building (Building 133) and creation of a single-chain-of-command governance structure for a joint federal health care facility.
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Hematology-Oncology Program (FY 2005) $685,000 A hematology-oncology program was added to include consultations, inpa tient support, outpatient care, and a chemotherapy infusion center for VA and DoD beneficiaries.
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. Interim Pharmacy Solution at the Lovell Federal Health Care Center (FY 2010)
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The HEC, at the urging of Vice Admiral Donald Arthur, the Navy surgeon general, directed the planning group to plan a fully integrated organization under a singleline-of-authority governance structure. The revised governance EDM listed the pros and cons for what it called the federal health care model, in which all services currently provided by the Navy and the VA in North Chicago would be located within a single organizational structure under a single chain of command.
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, budgeting, eligibility, and pharmacy. To identify these and explore the options for resolving any differences, the HEC chartered six national task groups: 1.
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. In a press release, Winkenwerder said that the process of combining the two health centers would be "difficult," but the benefit would be "the continued provision of accessible, high quality health care for active duty and veteran patients that benefits taxpayers through the reduction of costs by reducing duplication between these two health care delivery systems." He also said that the collaboration would "improve the seamless delivery of care to patients, from entry into the armed forces through veteran status" (Ellis, 2005)
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Table 3-2 summarizes the implementation issues likely to be encountered in creating other integrated VA/DoD health care centers, based on the Lovell FHCC experience.
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The Vision of a Federal Health Care Center The local leaders of the leadership task group -- the director of the NCVAMC7 and the current commander of the NHGL/NHCGL8 as well as key members of their staffs -- had a consistent vision of the way the Lovell FHCC should function to achieve its mission of providing seamless health care to all patients, regardless of their status as VA or DoD beneficiaries or providers. The vision was to have, to the fullest extent possible, one 6 The "big rocks" are enumerated in Hassan et al.
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Governance The governance goal was to create a unified management and accountability structure for an organization that was to be neither VA nor Navy but a blending of the best of both. The intent was to achieve efficiencies by reducing redundancies and to deliver seamless care to servicemembers and their family members whether they are active duty or veterans or transitioning from active duty to veteran status.
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An extensive executive sharing agreement between the department secretaries would be used to spell out how the FHCC would operate in an integrated fashion to provide seamless care to both VA and DoD beneficiaries. The intent was to have an organization that would seamlessly serve both DoD and VA beneficiaries yet be fiscally and operationally accountable for each agency's assets and costs.
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C ommunication and E A C ompliance Oper ational L ine of A uthor ity M ilitar y R epor ting R elationship & A ccountability FIGURE 3-1 Lovell Federal Health Care Center leadership organization chart. SOURCE: Lovell FHCC staff, October 2012.
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The vision of the Lovell FHCC planners was to serve all these TRICARE patient categories as if they were still using an MTF, that is, without imposing any cost-sharing requirements. It was feared that copayments would interrupt the continuity of care when DoD beneficiaries seen in the ACC (which could be designated as an MTF as long as the Navy retained ownership)
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Option 2 was to seek legislative relief to allow the FHCC to be "MTF-like" -- able to serve all DoD beneficiary groups without cost sharing. Option 3 was to have the VA part of the FHCC continue to be a TRICARE network provider, the arrangement in force since 2006 when all inpatient and emergency services for DoD beneficiaries were shifted to the NCVAMC.
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. Transfer of Ownership of the Ambulatory Care Center Facility Another big rock issue was the planned transfer of the Navy-built ACC to the VA.
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The legislation was reintroduced several more times as the Captain James A Lovell Federal Health Care Center Act before it was passed as part of the NDAA 2009.
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11 For example, DoD civilians have the right to appeal adverse personnel actions to the Merit Systems Protection Board, but Department of Veterans Affairs (VA) employees do not.
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Approximately a dozen active duty sailors and 10 Navy contractors at the NHCGL were noncitizens requiring an individual waiver. The NCVAMC, in contrast, employed many more noncitizens -- about 100 -- as medical students, interns, residents, and physicians, which would have overwhelmed the individual waiver process.
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Access Cards To provide seamless, coordinated, and safe care, VA employees need a way to access AHLTA and other DoD electronic information systems. Similarly, active duty personnel need a way to access the VA's Veterans Health Information Systems and Technology Architecture (VistA)
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Part of this goal was to fund the FHCC in a way that was not categorical, for example, "these are VA dollars that must be used for this but not for that," and "these are DoD dollars that can be used only for these purposes." Other aspects of what the FHCC planners called the "unified financial vision" are presented below. The Lovell FHCC could not receive funds directly from the DoD or the VA for the same reason it could not be run by a board of directors.
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Ambulatory Care Center Building and Equipment Ownership The original plan was to transfer the Navy-built ACC to the VA immediately, which, it was determined, would require legislation to permit. Subsequently, the Navy decided to hold off on transferring the building because of concern about losing MTF status for the ACC when it became apparent that the entire Lovell FHCC would not be designated as an MTF.
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, a managerial cost accounting system, could accurately allocate costs to the services provided to VA beneficiaries and DoD beneficiaries so that each department could be charged appropriately. The DSS was developed by adapting commercial software to interface with and be populated by VistA and other VA databases to provide data on costs of goods and services for patients down to the encounter and laboratory test level.
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is used to document and capture labor costs for active duty personnel, DoD contractors, and the few remaining DoD civilian positions. DMHRSi labor costs are then mapped into the DSS, which allows all FHCC costs to be contained within it.
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be added to the GLAC as sources of supplies and services. The NMLC was already being used for the PSCs for personnel working in the branch clinics on the east c ampus, because the VA does not have authority for PSCs and converting the contractors to federal civil service employees would have been much more costly.
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. Asset Management Like other administrative functions, the Lovell FHCC planners hoped to use one asset management system rather than two programs to enhance accountability and efficiency.
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The Lovell FHCC wanted to use the VA's CMOP service for DoD beneficiaries to save money and also to reduce waiting time at the space-limited pharmacy. The DoD does not participate in the CMOP and did not wish to set a precedent by making an exception for the FHCC.19 There was hope that the tri-service integration 19 The DoD experimented with the use of the Consolidated Mail Order Pharmacy (CMOP)
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The recommen dation was to use pharmacy technicians only at the Navy branch clinics, which did not require any rule changes and still contributed to the operational readiness of the Navy pharmacy technicians. • Ensuring patient safety.
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There was also a need for information recorded in VistA for Navy patients (e.g., inpatients, those using the ED, and those seeing VA specialists) to be replicated in AHLTA, so that their medical operational readiness could be determined and their medical records would be complete when they left for new assignments beyond North Chicago.
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VA provider access was on a read-only basis, which meant that information on inpatient, emergency, and specialty provider encounters on the west campus had to be entered into AHLTA separately. The information only pertained to "active dual consumers," that is, military retirees also eligible for VA health care, not active duty servicemembers who had not yet retired, such as the recruits, students, and staff at Great Lakes (although arrangements could be made -- and were -- to flag recruits and other active duty servicemembers at Great Lakes as active dual consumers)
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A tiger team was dispatched several times to North Chicago to identify the technical requirements for critical interoperability solutions -- including a single sign-on solution that would allow providers to log in once to see clinical data from both AHLTA and VistA (including the medical readiness status of active duty servicemembers)
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. However, the EA between the departments signed in April 2010 specified that single patient registration, single sign-on, and orders portability would be ready on opening day, as well as documentation of medical and dental operational readiness of recruits and other active duty servicemembers (DoD/VA, 2010, Attachment A)
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In February, the VA's chief information officer told Congress that single patient registration, single sign-on, and orders portability for laboratory, pharmacy, and radiology would not be ready until the end of November 2010 (and orders portability for consults not until later in 2011) , which would delay the move of the Navy's outpatient clinics to the ACC (U.S.
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The single patient registration and single sign-on with context management capabilities were delivered to the Lovell FHCC on December 13, 2010, and were operational by the end of the month, except for delays in access to single sign-on for some users and limitations on context management because of inconsistent family member codes between the DoD and the VA and other problems. Because of continuing problems with using two single sign-on with context management programs at Lovell, the IPO recently decided to use just one of the two programs for use in the iEHR system (Brewin, 2012)
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This capabil ity is complex to develop and, early in 2010, it was postponed until later in 2011, in favor of making single patient registration, single sign-on, and orders portability for laboratory, radiology, and pharmacy ready for the opening of the Lovell FHCC. Along with orders portability for pharmacy (see above)
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Plans for a Joint Department of Veterans Affairs/Department of Defense Electronic Health Record System In 2010, the VA and DoD secretaries began to meet every two months to discuss progress on developing a joint disability evaluation system to replace their separate systems and interoperability between their EHR systems, and the situation at the Lovell FHCC was an explicit agenda item. In early 2011, aware of major problems in the effort to develop interoperability software for use at the FHCC, they decided to halt the upgrade programs for their respective EHR systems, AHLTA and VistA, and instead develop a new EHR system for joint use, dubbed the iEHR.
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. Because it was determined that use of a single credentialing system did not meet VA and DoD organizational requirements, and that using an interface to create interoperability was not cost effective, Lovell FHCC planners proposed and the HEC co-chairs approved using CCQAS for active duty providers and VetPro for civilian providers and establishing a combined credentialing office in which staff would be cross-trained to use both systems.
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The VA wanted to use VA privileging policies for all providers at the Lovell FHCC, arguing that a scope of practice arrangement would maintain the clinical skills required for military operational readiness; the Navy wanted to privilege APNs, hospital corpsmen, and other health professionals as permitted by Navy policies. The Navy's position was that independent practice was needed to develop the critical thinking skills that such health professionals would need when deployed where there are no physicians to consult.
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The workaround was an agreement that hospital corpsmen can be supervised on a daily basis by VA nurses and meet Navy requirements as long as they have an active duty nurse mentor who meets with them regularly. Corpsmen, especially those with advanced training that qualifies them as independent duty corpsmen (IDCs)
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Some Navy personnel worried that the FHCC would encumber their mission of medically processing recruits and ensuring they were medically fit for deployment, while some veterans worried that they would receive lower priority than active duty servicemembers in obtaining services (Interviews)
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The FHCC's logo and motto -- "Proud to Partner: Excellence in Federal Health Care! " -- were developed early in the process (Lovell FHCC, 2006)
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Legislative Process The six task groups formed in 2005 were instructed to identify any laws, regulations, policies, and procedures that would have to be revised or dropped to enable the VA and the Navy to integrate their health care centers
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Finally, legislation would be needed to designate the FHCC as an MTF to enable it to provide health care to DoD beneficiaries without charging deductibles and copayments required if they used non-MTF facilities. In 2008, the congressional affairs offices of the VA and the DoD worked with members of the Illinois delegation to draft language permitting the transfer of personnel from the Navy to the VA, allowing the transfer of ownership of the ACC from the Navy to the VA, designating the Lovell FHCC as an MTF, and establishing a JIF-like mechanism to allow the department to fund the FHCC jointly.
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Instead, when the NDAA 2009 was passed by Congress, it included a section on "Guidelines for Combined Medical Facilities of the Department of Defense and the Department of Veterans Affairs" that required the DoD and VA secretaries to execute a binding operational agreement on nine areas: 1. Governance 2.
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The Durbin-Akaka bill provided for a Treasury fund under the VA to which the DoD and the VA could transfer funds for the FHCC, and it stipulated that the funds would be available for 1 FY, except for 2 percent, which could be carried over into a second year. After a fair amount of behind-the-scenes negotiating in the executive branch, and then between the House and the Senate, which had passed different versions of the NDAA 2010, the Department of Defense-Department of Veterans Affairs Medical Facility Demonstration Project was passed as part of the NDAA 2010 and signed into law on October 28, 2009.
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Some of the solutions developed by the Lovell FHCC might be adopted by future FHCCs. Many of them are compromises or time-consuming workarounds necessitated by differing policies and procedures of the VA, the DoD, and TABLE 3-2 Issues Likely to Be Encountered in Creating an Integrated Department of Veterans Affairs/Department of Defense Joint Health Care Center Implementation Issue Discussion Joint governance The desire to have a joint governance structure must be reconciled with the requirement that a federal health care center (FHCC)
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In a VA/DoD FHCC, active duty personnel will always be in a separate personnel system. However, civilians can be put under one department or the other, if Congress approves.
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at the FHCC was to allow corpsmen working on the west campus to be supervised by civilian nurses in their daily work as long as there is an active duty nurse mentor. Procurement There was agreement that the Lovell FHCC would use the VA procurement system, but experience has shown that it would be more cost effective if the Navy facilities command could be used for certain base operations.
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Mail order The Lovell FHCC saved space in the ambulatory care center by pharmacy deciding to rely on the VA's Consolidated Mail Order Pharmacy (CMOP) for prescription refills, but the DoD does not want to allow DoD beneficiaries to use this program.
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Lovell Federal Health Care Center Demonstration Project. Federal Register, September 27, pp.
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Provided to the IOM Committee on Evaluation of the Lovell Federal Health Care Center Merger by the Lovell FHCC. Maldonado, F
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Presentation by Dr. Robert Opsut, TRICARE Management Agency, DoD, to the IOM Committee on Evaluation of the Lovell Federal Health Care Center Merger, Washington, DC, February 25.
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2006b. VA/DoD Health Executive Council executive decision memorandum, Second call for Joint Incentive Fund (JIF)
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