Appendix C

Department of Veterans Affairs/Department of Defense Joint Ventures
1:Brief Histories and Lessons Learned

The committee reviewed the current nine formal joint ventures that share resources in a variety of arrangements, and arrived at its summary of lessons learned across them by considering the information collected from a number of sources (see Chapter 5).

ALBUQUERQUE, NEW MEXICO: 377TH MEDICAL GROUP, KIRTLAND AIR FORCE BASE/NEW MEXICO VETERANS AFFAIRS HEALTH CARE SYSTEM

Brief History

The first formally designated Department of Defense (DoD)/Department of Veterans Affairs (VA) joint venture was established in 1987 between the Air Force’s 377th Medical Group (377th MDG) at Kirtland Air Force Base (Kirtland AFB) and the New Mexico Veterans Affairs Health Care System (NMVAHCS), located in Albuquerque, New Mexico. The Kirtland AFB Hospital and the Albuquerque VA Medical Center (VAMC), located two miles apart, had shared some services since at least the 1970s, for example, laboratory tests performed at no cost by the VA for DoD patients in the early part of that decade. With an eye toward achieving efficiency and cost savings, DoD and VA officials in Albuquerque have envisioned, created agreements for, and supported the increase of their shared services. The first

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1 The Lovell FHCC is no longer formally classified as a joint venture because it is considered to be a unique organizational arrangement.



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Appendix C Department of Veterans Affairs/ Department of Defense Joint Ventures1: Brief Histories and Lessons Learned The committee reviewed the current nine formal joint ventures that share resources in a variety of arrangements, and arrived at its summary of lessons learned across them by considering the information collected from a number of sources (see Chapter 5). ALBUQUERQUE, NEW MEXICO: 377TH MEDICAL GROUP, KIRTLAND AIR FORCE BASE/NEW MEXICO VETERANS AFFAIRS HEALTH CARE SYSTEM Brief History The first formally designated Department of Defense (DoD)/Department of Veterans Affairs (VA) joint venture was established in 1987 between the Air Force’s 377th Medical Group (377th MDG) at Kirtland Air Force Base (Kirtland AFB) and the New Mexico Veterans Affairs Health Care System (NMVAHCS), located in Albuquerque, New Mexico. The Kirtland AFB Hospital and the Albuquerque VA Medical Center (VAMC), located two miles apart, had shared some services since at least the 1970s, for example, laboratory tests performed at no cost by the VA for DoD patients in the early part of that decade. With an eye toward achieving efficiency and cost savings, DoD and VA officials in Albuquerque have envisioned, created agreements for, and supported the increase of their shared services. The first 1  TheLovell FHCC is no longer formally classified as a joint venture because it is considered to be a unique organizational arrangement. 199

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200 LOVELL FEDERAL HEALTH CARE CENTER MERGER formal sharing agreement was signed in March 1976. Under the agreement, the VA provided medical services and laboratory tests on a reimbursement basis. In the 1980s, the Air Force was faced with renovating its hospital at a cost of $26 million at the same time that the VA was planning the construction of a new Albuquerque VAMC. Rather than renovate the Air Force hospital, the VA agreed to include a 40-bed inpatient medical-surgical unit for the 377th MDG to staff and manage in the new VA facility, to be called the New Mexico Regional Federal Medical Center, which opened in 1987. The Air Force also agreed to manage the emergency room and, in 1989, constructed an ambulatory care center next to the hospital. The VA provided all ancillary services to the Air Force–staffed inpatient unit. The joint venture underwent a major change in 2002, when the Air Force, due to substantial reductions in personnel stationed at Kirtland, closed the inpatient unit and revised the interagency sharing agreement to allow the purchase of inpatient services from the VA (GAO, 1978; Simmons, 1989; VA/DoD, 2002). In a recent development, the DoD invested $2.9 million for the reno- vation of its same-day-surgery unit, which was completed in 2011. As of the end of February 2012, the director of the joint venture indicated that the associated sharing agreement is pending review and approval by the Air Force Medical Support Agency, and the reopening was anticipated for March 2012.2 The sharing agreement will be between the 377th MDG and the NMVAHCS for the VA to occupy DoD ambulatory surgery space in exchange for providing 30 free surgeries a month for DoD beneficiaries (VA/DoD, 2011b). Lessons Learned Lessons learned at the Albuquerque joint venture include that success- ful agreements are worked out over time and through extensive planning efforts. Sharing agreements or joint ventures are unique to their locations and will not work unless the arrangement is cost effective for both partners. Leadership, personalities, and communications are important, and cultural issues must be overcome. Leadership needs to make strategic plans in the anticipation of accommodating the fluctuating availability of resources in an unpredictable environment. Sharing partners and their leaders must be committed, flexible, open-minded, and patient in their planning efforts, and they must look for opportunities to expand and modify arrangements as needed (Anderson, 1995; Baine, 1995; Carlton, 2000; Rogers, 2007; Spaulding and Catton, 2008; VA/DoD, 2011b). 2  Personalcommunication with Patricia L. Ospino, M.B.A., Joint Venture Director, Febru- ary 24, 2012.

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APPENDIX C 201 EL PASO, TEXAS: WILLIAM BEAUMONT ARMY MEDICAL CENTER, FORT BLISS/EL PASO VETERANS AFFAIRS HEALTH CARE SYSTEM Brief History The William Beaumont Army Medical Center (WBAMC) and the El Paso Veterans Affairs Health Care System (EPVAHCS) have shared re- sources since the early 1970s. At that time, the VA canceled plans to build a hospital in El Paso when the Army agreed to provide inpatient care to VA beneficiaries in the WBAMC, which was then under construction. The El Paso DoD/VA joint venture started in 1987, when the VA needed to re- place its outpatient clinic. A working group between the two organizations agreed to an arrangement in which the VA built its new, larger VA Eastside El Paso Clinic (VA Clinic) adjacent to the WBAMC. The clinic opened in 1995, and each floor is physically connected and has open access to the WBAMC. The Army provides inpatient care to VA beneficiaries in El Paso, who account for 26 percent of inpatient services provided at the WBAMC. VA staff share an 8-room ambulatory surgical suite and 16-bed recovery area on the fourth floor of the WBAMC with Army staff. The VA Clinic’s staff provides primary and behavioral health care, specialty services, den- tal services, and ambulatory surgery to veterans and has two ambulatory surgery suites available for use by the WBAMC. In 2008, the VA opened a 29,000-square-foot addition to the clinic for physical therapy, behavioral health, and podiatry programs. While the WBAMC underwent renovations to its post-anesthesia care unit (completed in 2009), the VA allowed Army staff to use the ambulatory surgery suite in the clinic. The Texas Tech Uni- versity School of Medicine has a consortium agreement with the EPVAHCS and the WBAMC to train residents in internal medicine and psychiatry. The WBAMC’s graduate medical education program (GME) is open to VA medical residents (AMEDD, 2012; DoD/VA, 2002, 2008b; GAO, 2007; Hite, 2011; U.S. Senate, 1980; VA, 2012b; VA/DoD, 2002, 2006). Because of Defense Base Realignment and Closure (BRAC) actions and other shifts of personnel, Fort Bliss is expanding substantially. By 2014, it is slated to be the third largest Army installation in the United States after Fort Bragg and Fort Hood. TRICARE Prime enrollment at the WBAMC is expected to double, to more than 110,000. In anticipation of this large increase in demand for health care, the Army began to plan for a major expansion of health care facilities, including a new $966 million hospital in a new location about 10 miles away in East El Paso. The new WBAMC hospital replacement project was awarded in 2009, ground was broken in 2011, and the inpatient facility is scheduled to open in 2016 (Wirtemburg and Ancker, 2008).

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202 LOVELL FEDERAL HEALTH CARE CENTER MERGER The VA wanted to relocate with the new Army facility and possibly share space for outpatient services—rather than build a separate ambu- latory care facility—and also possibly jointly staff ambulatory surgery services. The VA is expecting its patient load to increase by nearly 5,000, to 41,000, and also wanted its clinic to be near the new access to the emer- gency room and specialty consultations at the new WBAMC, and to have continuity of care, sharing of ancillary services, and better GME opportuni- ties. There was an effort to size the new inpatient facility to provide services for both DoD and VA beneficiaries, with the VA paying a proportionate share of the construction costs (approximately 25 percent), but differing construction planning and funding cycles made this approach impossible to achieve. In August 2012, Army Major Bryan Walrath, program manager for the U.S. Army Health Facility Planning Agency, reported that what will happen to the Beaumont facility is yet to be determined, indicating that “a big part of that question will be answered when it’s known if the Veterans Administration clinic, now located in a wing attached to Beaumont, will stay or eventually move to its own facility at the new hospital site” (Kolenc, 2012). Lessons Learned Lessons learned in El Paso include that open communication and in- formation sharing are paramount to the success of a joint venture, and that trust and cooperation are key elements of the collaboration. There must be strong and committed leadership and a solid management structure, includ- ing middle management as well as subcommittees and work groups, suffi- cient to cohesively address important issues. DoD/VA team members (along with leadership as needed) should brainstorm together in a joint effort to resolve the major issues and creatively collaborate on plans and documenta- tion. This kind of communication involves being specific about situations that arise to encourage more targeted discussions and practical solutions and to create a paper trail. By doing this, staff from both organizations will come to understand each other better and identify with the positive com- munity effort they are undertaking. Staff should also commingle as much as possible to further their community identification. Unions should be part of the discussions from the beginning and as often as feasible (Perdue and Ancker, 2007, 2011; VA/DoD, 2006; Wirtemburg and Ancker, 2008).

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APPENDIX C 203 HONOLULU, HAWAII: TRIPLER ARMY MEDICAL CENTER/ VETERANS AFFAIRS PACIFIC ISLANDS/HEALTH CARE SYSTEM (SPARK M. MATSUNAGA MEDICAL CENTER) Brief History The Tripler Army Medical Center (TAMC) and the Veterans Affairs Pa- cific Island Health Care System (VAPIHCS) joint venture is unusual because it was established through a 1991 memorandum signed by Hawaii Senator Daniel Inouye and by Undersecretary of the Army John W. Shannon. It became an official joint venture in 1992. Its purpose was to provide a bet- ter and broader range of health care for beneficiaries and to promote the use of a single inpatient facility that would obviate the need for the VA to build one separately, thus reducing both construction costs and the expense associated with beneficiaries going out to the community to seek medical care. In this sharing arrangement, the TAMC hosts the VA, with VA staff providing outpatient, mental health, dental health, and nursing home care. The VAPIHCS arranges and pays for the care of veterans at the TAMC, in the local community, or at VA facilities in California as needed (AMEDD, 2011; Hite, 2011; Perlin, 2006). TAMC’s E-Wing inpatient ward, staffed by VA personnel, was estab- lished in 1994, was renovated in 1999, and became the site of the VA’s Re- gional Office Center and the VAPIHCS administrative services in 2000. In 1997, the VA Day Hospital Program was relocated to the campus adjacent to the VA-staffed psychiatric ward. A new parking facility and the Center for Aging were completed in 2000. That same year, the VAPIHCS Spark M. Matsunaga VA Ambulatory Care Center, located adjacent to the TAMC campus, opened and began to provide primary care services, including mental health, specialty services, radiology, and optometry. The VA’s Post- Traumatic Stress Disorder Recovery Rehabilitation Program residential program relocated to the fifth floor of the TAMC after moving from Hilo in 2006. The first telehealth initiative began in 2009, as did the opening of the VA Dialysis Unit managed by VA staff for the use of both VA and DoD beneficiaries. A Joint Sleep Studies Unit was completed in 2010 (AMEDD, 2011; Committee on Veterans’ Affairs, U.S. Senate, 2002; DoD, 2010; Hite, 2011; Pacific Region Health Systems, 2011; Perlin, 2006). Lessons Learned The Hawaii joint venture offers a number of lessons learned. Good leadership from both partners that creates a cooperative atmosphere based on mutual trust and from staff who address issues on an ongoing basis is needed. Sharing equally and reaching consensus despite differences between

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204 LOVELL FEDERAL HEALTH CARE CENTER MERGER the organizations are important, with the underpinning of well-documented agreements and understandings. It is important for both organizations to be dedicated to the common joint venture mission, to work hard and envi- sion success, and to further progress by developing new initiatives created by working groups and multidisciplinary teams. To accomplish the joint venture goals, open and honest communication is paramount, as is creative thinking to find solutions. Patients need to be the focus (patient-centered care) while saving money in the federal health care system at the same time (Horner and Holes, 2007, 2008; Horner et al., 2006). Potential Contributions to Other Joint Ventures and Sharing Locations The Hawaii joint venture has provided potentially useful electronic sharing technology models for other joint venture and sharing agreement arrangements. Its pilot project graphic user interface (GUI), or Janus, is a promising technological collaborative development with Pacific Telehealth & Technology Hui that was begun in 2003. In 2011, it was announced that Janus would be used as part of the VA’s joint electronic health record to access records and radiological imagery, including laboratory and phar- macy, allowing clinicians to view data from the two systems, and that the single GUI for the Veterans Health Information Systems and Technology Architecture (VistA) and the Armed Forces Health Longitudinal Technology Application (AHLTA) was being tested in the Tripler Army Medical Center in Honolulu. Future capabilities for Janus II are being developed through collaboration with the same company and will include intranet capabilities and radiology imaging sharing. In 2008, document management and refer- ral management tools with four modules—bi-directional enhanced docu- ment referral (eDR) system, Charge Master Billing System, Joint Analytic Repository, and VistA Fee/IPAC Interface (a patch that allows the VA to pay the DoD within the VistA system)—were tested and implemented. A 2010–2012 joint venture objective is to follow up on the implementation of the eDR system and make it more efficient as an evaluation tool. If this effort is successful, it will lead to national implementation of the system at all joint venture sites as part of Joint Marketing Opportunities efforts (Brewin, 2011; Horner and Holes, 2007, 2009; Kyte and Camara, 2006; Perera, 2011; VA/DoD, 2007, 2008b, 2009a).

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APPENDIX C 205 FAIRFIELD, CALIFORNIA: 60TH MEDICAL GROUP, DAVID GRANT MEDICAL CENTER, TRAVIS AIR FORCE BASE/NORTHERN CALIFORNIA VETERANS AFFAIRS HEALTH CARE SYSTEM Brief History The 1988 and the 1995 BRAC actions led to changes in the Mather and the McClellan Air Force Bases, located in Sacramento and McClellan, California, respectively. Mather became the Sacramento VA Medical Cen- ter and McClellan became a VA outpatient clinic with a DoD satellite clinic. With these developments as a backdrop, the 235-bed VA hospital in Martinez, California, closed in 1991 because of concerns that it was not safe in the event of earthquakes. A replacement clinic was built and opened in November 1992. It was regarded as a desirable VA prototype because veterans were provided a number of outpatient services they had not had before, including surgery and state-of-the-art technology. In 1994, the Air Force and its David Grant Medical Center (DGMC)/60th Medical Group (60 MDG), located at Travis Air Force Base (Travis AFB), and the Northern California Veterans Affairs Health Care System (NCVAHCS) formed a joint venture that allowed the VA to provide health care services to veterans in space allocated to them at the DGMC. This sharing agreement allowed veterans to use the emergency room, receive inpatient care, access radia- tion therapy, and receive specified diagnostic services. The medical/surgical unit at the DGMC (No. 5150) was operated by VA staff, while there was joint staffing at the inpatient psychiatric unit. In 1996, the VA proposed the construction of a new VA hospital, a VA outpatient clinic, and renovation to its DGMC space, but Congress decided that building a smaller outpa- tient clinic at Travis AFB and working through contractual arrangements would be sufficient for the VA’s needs. The sharing agreement between the DoD and the VA was renewed in 2008; the current joint venture services include the above, as well as dialysis, inpatient mental health, laboratory, radiology, and pharmacy (DGMC/VANCHCS, 2006; GAO, 1996a,b, 1998, 2004; Hite, 2011; Mosher et al., 2009; Scharenbrock and Carlson, 2010; Wilder and Kelly, 2011). The key locations for the services of this joint venture are the DGMC and the VA Fairfield Outpatient Clinic, which opened in 2001, in Fairfield, California. This is a good location because it is situated at a midpoint on the I-80 corridor between East Bay and Sacramento with the VA Medi- cal Center located in Sacramento, and the outpatient clinics in Alameda and McClellan. The VA’s Sacramento site is the location of the McClellan 60 MDG satellite clinic that provides services for DoD beneficiaries. The joint venture educational partnership is with the University of Califor- nia, Davis, which is located near the DGMC (Allen and Carlson, 2009;

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206 LOVELL FEDERAL HEALTH CARE CENTER MERGER DGMC/VANCHCS, 2006, 2011; DoD, 2001; VA/DoD, 2000; Wilder and Kelly, 2011). Lessons Learned The need to have strong leadership, a single joint venture business of- fice, an “operations guide,” and an organizational chart on which to base the hiring of personnel are all offered as lessons that have been learned through this joint venture experience (DGMC/VANCHCS, 2011). In 2011, current leadership from the Air Force and the VA discussed lessons they have learned from this joint venture. They said that a major factor in determining how well a model might work in a given location should be in the assessment of the degree of mutual dependence. Before even entering into collaboration projects, it is important to research the availability of extant federal facilities (Wilder and Kelly, 2011). With the establishment of a joint venture, they stressed the importance of the partners meeting regularly and developing a joint strategic plan, including those to address information technology issues. Joint venture management personnel also need to work closely with veterans groups to establish trust, including sharing Joint Incentive Fund proposals with them and asking for comments (Wilder and Kelly, 2011). When it comes to operations, both partners need to “stand at orienta- tion” to mitigate cultural issues and promote high standards. Staff who are dedicated to the joint venture will create a smoother operation, so it is important to communicate common goals effectively, from the leadership level to personnel attending to day-to-day clinical care. This can be ac- complished by shared strategic planning sessions (established between the Air Force and the VA in 2006 for the Northern California joint venture) to cement the partnership. In this case, a 3- to 5-year plan has been created on the premise of mutual dependency with mutual benefits and efforts to “understand each other’s culture” (Wilder and Kelly, 2011). Effective planning for construction projects and health facilities is important. For example, Travis AFB can bring in the VA as part of the planning process, such as the joint musculoskeletal rehabilitation facility (Wilder and Kelly, 2011). As for the potential for a merger in Northern California, the leadership indicated that they felt it would be plausible, but that there would need to be a unified operational mechanism for supervision rather than two sepa- rate entities, e.g., VA employees and the military. However, a single chain of command and one physical “pot of money” would be better than “shuffling the money back and forth” (Wilder and Kelly, 2011).

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APPENDIX C 207 LAS VEGAS, NEVADA: 99TH MEDICAL GROUP, NELLIS AIR FORCE BASE/VETERANS AFFAIRS SOUTHERN NEVADA HEALTHCARE SYSTEM Brief History The joint venture between Nellis Air Force Base’s 99th Medical Group (99th MDG) and the Veterans Affairs Southern Nevada Healthcare System (VASNHS) started operations in 1994 with the opening of a new hospital on the base to replace the outdated hospital constructed in 1965. Dedicated as the Mike O’Callaghan Federal Hospital (MOFH) in 1996, the new facil- ity marked the first hospital construction project jointly funded and planned as an “operational joint venture” by the Air Force and the VA, although the two organizations had shared resources well before then. Currently, the MOFH has 114 beds (62 DoD and 52 VA). This arrangement promotes the sharing of costs between the two organizations and the opportunity for veterans to have access to services in Las Vegas, which they had not had previously. Inpatient, limited outpatient, some parts of intensive care and the step-down unit, psychiatric, and emergency room services are shared. Staffing is complex, with some degree of integration. Planning for a new, collocated Las Vegas VAMC began in 2003 and the center opened in August 2012, with the capacity of 90 inpatient beds (22 mental health unit, 48 medical/surgical, and 20 intensive care unit), and launching with an operational outpatient mental health clinic. From August through De- cember 2012, there will be a phased opening of other services, including the provision of “23 dental exam chairs; 13 surgical, 14 radiology, and 6 audiometric sound suites,” and featuring “a telehealth unit, with bidi- rectional just-in-time communication capability with its outlying clinics” (VA, 2012d). With the opening of the center, sharing agreements will be enhanced, allowing Air Force patient access to clinical services currently not available at the MOFH (Collins, 2011; Hite, 2011; Irwin and Drew, 2008; MOFH, 2006; Nellis Air Force Base, 2012; Nicholson, 2005a,b; Roadman, 1999; Simmons, 1989; VA, 2006, 2007b; VA/DoD, 2002). The Mike O’Callaghan Federal Hospital Before 1994, VA beneficiaries did not have access to VA inpatient ser- vices in Las Vegas and they had to travel to facilities in Southern California for their care. Alternatively, DoD beneficiaries had more limited access to specialized providers prior to 1994 than after the establishment of the joint venture. In fiscal year (FY) 1990, the Air Force contributed $58 million and the VA $7 million to build the MOFH. After its 1994 opening, some opera- tional difficulties arose, one of which was not having a system to adequately

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208 LOVELL FEDERAL HEALTH CARE CENTER MERGER address disputes. A high-level Air Force and VA team was brought in to help resolve issues. In 1999, complications came about because of cost ac- counting issues, bringing to light the need for joint venture partners to have interoperable information systems. In 2002, more serious concerns about inefficiency thought to be brought about by insufficient sharing efforts between the Air Force and the VA were reported. Over time, both limited space and the MOFH concerns about the availability of beneficiary services needed to be addressed. In response, a new VA medical campus complex was proposed, approved, and subsequently funded (DoD/VA, 2002; GAO, 2004; Principi, 1999; VA/DoD, 1995). Collocated VA Medical Campus Complex In 2003, the VA sought a permanent location for an ambulatory care center in Las Vegas, intended to meet the needs of both the VA and the DoD, and a recommendation to build a new hospital there was made in 2004. The location was within a few miles of the MOFH facility. FY 2006 Capital Asset Realignment for Enhanced Services funding supported this construction project for a total estimated cost of $600.4 million (Collins, 2011; Ensign, 2007; MOFH, 2006, 2007; Nicholson, 2005a,b; Panangala, 2005; VA, 2003, 2007a, 2008). The state-of-the-art VA medical center opened on August 6, 2012. At the dedication, Colonel John DeGoes, the 9th Medical Group commander, commented that “this is not a divorce” and that the joint venture “will continue in Las Vegas long into the future” with “two outstanding medical centers, separated by only four miles” (Sanders, 2012). Lessons Learned Lessons learned in Las Vegas include that it is important to establish trust between the partners, and leadership, as well as an effective executive council, sets the tone. A joint venture is a partnership in which a single set of standards should be set forth. Both partners need to maintain consistent and open dialogue to reach their common goals and successfully share re- sources for the benefit of each of the populations represented. Key concerns and other issues should be recorded in formal minutes, and focusing on insignificant issues should be avoided. There should be flexibility in hiring, particularly for emergency room operations, personnel should be jointly trained from the outset, and dual credential/privileging workarounds be- tween the DoD and the VA personnel should be created. In a few specific operational areas, the reimbursement methodology needs to be sufficient; computing technology should be adequate for unique joint venture needs; and equipment such as a patient lift system can minimize patient and staff

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APPENDIX C 209 injuries. Staff should also chronicle clinical experiences so that lessons learned can be shared for the benefit of patients and staff (e.g., that fall pa- tients need to be actively monitored and that the early detection of MRSA [methicillin-resistant Staphylococcus aureus] minimizes internal nosocomial infection and reduces the patient’s stay) (Benjamin and Feistman, 2008; DoD/VA, 2008a; Mietzner and Gerrard, 2009; VA/DOD, 2011a). ANCHORAGE, ALASKA: 3RD MEDICAL GROUP, ELMENDORF AIR FORCE BASE/ALASKA VETERANS AFFAIRS HEALTH CARE SYSTEM Brief History Challenges in providing health care services to VA and DoD beneficia- ries in Alaska include accessibility (long distances, rugged terrain, severe weather, a limited road system, air evacuation often needed for patient transportation); transportation costs associated with the availability of medical services and clinicians (particularly specialty); the size of the popu- lations served (e.g., sparse in some of the more remote locations); and the opportunity for military clinicians to maintain and improve their skills through the opportunity to consistently work with patients from a broad- based population (Alaska Joint Venture, 2006). In 1986, the Alaska Veterans Affairs Health Care System and the Air Force initiated a collaborative effort to provide inpatient services to both VA and DoD beneficiaries in a jointly planned, funded, and staffed hospital located on the Elmendorf AFB near Anchorage, Alaska. (The base has been named Joint Base Elmendorf-Richardson since 2010, when Elmendorf AFB and the Army’s Fort Richardson were combined under the BRAC action in 2005.) The existing Air Force hospital at Elmendorf needed to be renovated and expanded to serve DoD beneficiaries. VA patients were being treated in area private hospitals because there was no VA inpatient facility. In 1992, after review of the original concept of operations (ConOps) that had been developed 2 years earlier (and was revised in 1998), the Air Force and the VA agreed to build a new hospital together and operate it jointly through a set of sharing agreements. The purposes of the joint venture were to use federal construction dollars more cost effectively, provide inpatient services directly to VA patients at lower cost, reduce per patient operating costs, and increase access and quality of care for both sets of beneficiaries (Alaska Joint Venture, 2006; GAO, 2004). The project became a formal VA/DoD joint venture in 1999, and ad- ditional opportunities to collaborate for the mutual benefit of agencies and their beneficiaries have been identified and pursued since that time. Most significantly, in May 2010, the VA opened a new outpatient clinic located

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216 LOVELL FEDERAL HEALTH CARE CENTER MERGER Lessons Learned In 2006, the GAO issued a report on the VA’s experiences in trying to forge partnerships with medical affiliates, specifically, in Denver and Charleston. Although the VA did not support the proposal for a joint venture in Denver, the partnership between the VA and the MUSC in Charleston was still being studied at that time and no final decision had yet been made. The GAO indicated that the Charleston and the Denver experi- ences yielded the following lessons: “criteria at the departmental level help provide clarity and consistency in evaluation approach; a communications strategy helps avoid misinformation and confusion; leadership support facilitates negotiations; and extensive collaboration assists negotiations” (GAO, 2006, Highlights). In 2011, the following lessons learned about what is needed for or what should be considered when undertaking a joint venture included “exclusionary fiscal processes/seamless flow of money; ser- vice footprint with measurable metrics; joint basing considerations; infor- mation technology interoperability; and deployment and staffing turnover impact” (Joint Venture Review, 2011, p. 15). REFERENCES Alaska DoD (Department of Defense)/VA (Department of Veterans Affairs) Joint Venture Hospital. 2011. Alaska DoD/VA Joint Venture Hospital. 2011 VA/DoD Joint Venture Conference, October. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Elmendorf Joint Venture] (accessed November 29, 2011). Alaska Joint Venture. 2006. Alaska joint venture. Presentation at 2006 Joint Venture Con- ference, February. www.tricare.mil/DVPCO/bummed/Navy%20JV%20Conf.Feb06.ppt (accessed October 28, 2011). Allen, M., and K. C. Carlson. 2009. David Grant USAF Medical Center, VA Northern Califor- nia Health Care System. Presentation by Col. Mark Allen, David Grant USAF Medical Center, and Ms. K. C. Carlson, VA Northern California Health Care System. http://www. tricare.mil/DVPCO/SharingConf.cfm (June 4, 2009, Breakout 7B—Joint Venture Update, Northern California VAHCS/Travis AFF) (accessed December 6, 2011). AMEDD (U.S. Army Medical Department). 2011. Current AMEDD/VA joint ventures: Tripler Army Medical Center/VA Pacific Island Health Care System (VAPIHCS). http://vadodrs. amedd.army.mil/JV/JointVentures.html (accessed November 3, 2011). AMEDD. 2012. William Beaumont Army Medical Center. http://www.wbamc.amedd.army. mil/ (accessed February 10, 2012). Anderson, D., and A. Kurzejeski. 2007. Alaska VA/3MDG demonstration project: Presentation by Dan Anderson, 3rd Medical Group JV Coordinator, and Adam Kurzejeski, Alaska VA JV Coordinator. 2007 Joint Venture Conference, March 6. http://www.tricare.mil/ DVPCO/el-paso/Elmendorf%20Demo%20Update.ppt (accessed October 28, 2011). Anderson, G. K. 1995. Statement of Maj. Gen. George K. Anderson, USAF, MC, Deputy As- sistant Secretary of Defense, Health Services Operations and Readiness, Department of Defense. Hearing on VA/DoD Sharing before the Committee on Hospitals and Health Care, Committee on Veterans’ Affairs, House of Representatives, October 18. http:// democrats.veterans.house.gov/hearings/schedule104/transcript104/sn104-12.htm (ac- cessed January 17, 2012).

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APPENDIX C 217 Baine, D. P. 1995. Statement of David P. Baine, Director, Health Care Delivery and Quality Issues, Health, Education, and Human Services Division, GAO. Hearing on VA/DoD Sharing before the Committee on Hospitals and Health Care, Committee on Veterans’ Affairs, House of Representatives, October 18. http://democrats.veterans.house.gov/ hearings/schedule104/transcript104/sn104-12.htm (accessed January 17, 2012). Beaufort, SC. 2012. Naval Hospital Beaufort. http://www.beaufortsc.org/military/naval- hospital-beaufort.stml (accessed January 26, 2012). Benjamin, C., and A. M. Feistman. 2008. The Mike O’Callaghan Federal Hospital: 99th Medi- cal Group and VA Southern Nevada Healthcare System. Presentation by Chris Benjamin, Col, USAF, and Ann Marie Feistman, FACHE. 2008 VA/DoD JV Conference. http://www. tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20-%20Las%20Vegas%20JV%20 MOFH%20(99MDG-VASNHCS).ppt (accessed January 5, 2012). Blair, H., and B. Cecil. 2007. Alaska VA/3MDG joint venture. Presentation by Hal Blair, Associate Director, Alaska VA, and COL Billy Cecil, Deputy Commander, 3rd Medi- cal Group. 2007 Joint Venture Conference, March 6. http://www.tricare.mil/DVPCO/ el-paso/Elmendorf%20JV%20Update.ppt (accessed October 28, 2011). Brewin, B. 2011. Joint health record graphical interface contest. May 26. http://whatsbrewin. nextgov.com/2011/05/joint_health_record_graphical_interface_contest.php (accessed No- vember 8, 2011). Carlton, P. K. 2000. Statement of Lt. Gen Paul K. Carlton, Jr., Surgeon General, United States Air Force. VA/DoD health care sharing. Hearing before the Subcommittee on Health of the Committee on Veterans’ Affairs, House of Representatives, May 17. Serial No. 106- 39. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/ cgi-bin/getdoc.cgi?dbname=106_house_hearings&docid=f:66495.pdf (accessed January 17, 2012). Charleston Joint Venture. 2009. Success stories on sharing: Joint clinics (Charleston, SC). Power of VHA DOD Sharing Conference, June 3. http://www.tricare.mil/DVPCO/ downloads/20090625/Breakout5aSuccessStoriesJointClinicsCharleston.ppt (accessed January 26, 2012). Cleckley, J., and H. Ramirez. 2008. Key West VA/DoD joint venture: Naval Medical Clinic Key West/Miami VA Health Care System. Lieutenant Janiese Cleckley, BHC Key West, and Dr. Hector Ramirez, VA Miami, 2008 Joint Venture Conference. http://www.tricare.mil/ DVPCO/Hawaii/2008%20JV%20Conf%20-%20Key%20West%20JV%20(NBHCKW- MVAHCS).ppt (accessed February 16, 2012). Cleckley, J., and H. Ramirez. 2009. Naval Branch Health Clinic & VA Outpatient Clinic Key West, FL. Presentation by LT Janiese Cleckley, NBHC Key West, and Dr. Hector Ramirez, VA Key West. 2009 Joint Venture Conference. http://www.tricare.mil/DVPCO/ downloads/20090625/Breakout3dJVUpdateKeyWest.ppt (accessed February 16, 2012). Collins, C. 2011. VA medical centers: Bigger and better. December 25. Defensemedianetwork. http://www.defensemedianetwork.com/stories/va-medical-centers-bigger-and-better/ (ac- cessed July 5, 2012). Committee on Veterans’ Affairs, U.S. Senate. 2002. The fiscal year 2003 budget for vet- erans’ programs. Hearing before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 107-744, February 14. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=107_senate_ hearings&docid=f:82502.wais.pdf (accessed November 3, 2011). Cornum, K., and T. Wisnieski. 2010. Biloxi/Keesler joint venture site. Presentation by Brig. Gen. Kory Cornum and Mr. Thomas Wisnieski, MPA, FACHE. 2010 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/lvjvc.cfm (accessed November 11, 2011).

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218 LOVELL FEDERAL HEALTH CARE CENTER MERGER DGMC (David Grant USAF Medical Center)/VANCHCS (Veterans Affairs Northern Califor- nia Health Care System). 2006. David Grant Medical Center, VA Northern California Health Care System: Joint venture overview. Presentation at the 2006 VA/DoD Joint Venture Conference. www.tricare.mil/DVPCO/bummed/DavidGrant.ppt (accessed De- cember 6, 2011). DGMC/VANCHCS. 2011. David Grant USAF Medical Center, VA Northern California Health Care System: Joint venture review. Presentation at 2011 VA/DoD Joint Venture Confer- ence. http://www.tricare.mil/DVPCO/CJVC2011.cfm (David Grant Joint Venture) (ac- cessed December 6, 2011). DoD. 2001. Department of Defense appropriations for fiscal year 2002. Hearings before the Subcommittee on Defense of the Committee on Appropriations, United States Senate, H.R. 338, S. Hrg. 107-233, February 28. Washington, DC: U.S. Government Print- ing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2002_sapp_ def_1&docid=f:70712.pdf (accessed December 5, 2011). DoD. 2010. Department of Defense appropriations for fiscal year 2011. Hearings before the Committee on Appropriations, United States Senate, S. 3800. http://www.gpo.gov/fdsys/ pkg/CHRG-111shrg54962/pdf/CHRG-111shrg54962.pdf (accessed January 5, 2012). DoD/VA. 2002. Department of Defense and Department of Veterans Affairs health resources sharing: Staff report to the House Committee on Veterans’ Affairs, February 25. Pp. 123–140 in Health care sharing by the Department of Defense and the Department of Veterans Affairs’ hearing before the Health Subcommittee of the Committee on Veterans’Affairs and the Military Personnel Subcommittee of the Committee on Armed Services, House of Representatives, March 7. Washington, DC: U.S. Government Print- ing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=107_house_ hearings&docid=f:80528.pdf (accessed February 9, 2012). DoD/VA. 2006. Navy Branch Health Clinic & VA Outpatient Clinic, Key West, FL. Presenta- tion. 2006 Joint Venture Conference. www.tricare.mil/DVPCO/bummed/KeyWest.ppt (accessed February 16, 2012). DoD/VA. 2008a. Department of Defense (DoD)/Veterans Affairs (VA) Joint Market Opportu- nities Work Group update. C&CS Communications and Customer Service Conference. http://tricare.mil/conferences/ccs2008/breakout.cfm (accessed August 30, 2012). DoD/VA. 2008b (July). Fiscal year 2003 National Defense Authorization Act. Department of Defense and Department of Veterans Affairs Demonstration Projects. Final report. Washington, DC: DoD/VA. Duren, R. 2005. Ground broken on new day in VA/DoD ‘joint’ health care. Naval Hos- pital Pensacola Public Affairs, May 11. http://www.navy.mil/search/display.asp?story_ id=18277 (accessed November 10, 2011). Duren, R. 2008. Military Medicine teams with VA to open joint out-patient facility. Naval Hospital Pensacola Public Affairs, September 19. http://www.globalsecurity.org/military/ library/news/2008/09/mil-080919-nns03.htm (accessed November 10, 2011). Ensign, J. 2007. Prepared statement of Hon. John Ensign, U.S. Senator from Nevada. Hearing on construction and lease authorization needs of the Department of Veterans Affairs. Hearing Before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 109- 561, April 6. Washington, DC: U.S. Government Printing Office. http://frwebgate.access. gpo.gov/cgi-bin/getdoc.cgi?dbname=109_senate_hearings&docid=f:28176.pdf (accessed January 5, 2012). GAO (U.S. General Accounting Office). 1978 (June 14). Legislation needed to encourage bet- ter use of federal medical resources and remove obstacles to interagency sharing. Report to the Congress of the United States by the comptroller general. HRD-78-54. Washing- ton, DC: GAO. http://archive.gao.gov/f0902a/106271.pdf (accessed February 16, 2012).

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APPENDIX C 219 GAO. 1996a. VA health care: Travis Hospital construction project is not justified. Report to the Chairman, Subcommittee on VA, HUD, and Independent Agencies, Committee on Appropriations, U.S. Senate. GAO/HEHS-9-198. Washington, DC: GAO. http://www. gao.gov/archive/1996/he96198.pdf (accessed December 5, 2011). GAO. 1996b. VA health care: Travis Hospital construction project is not justified. Summary and matters for congressional consideration. Washington, DC: GAO. GAO/HEHS-9-198. http://www.gao.gov/products/157398 (accessed December 5, 2011). GAO. 1998. VA hospitals: Issues and challenges for the future. GAO/HEHS-8-32. Washing- ton, DC: GAO. http://www.gao.gov/archive/1998/he98032.pdf (accessed December 5, 2011). GAO. 2000. VA and Defense health care: Evolving health care systems require rethinking of resource sharing strategies. Washington, DC: GAO. http://www.gao.gov/archive/2000/ he00052.pdf (accessed February 16, 2012). GAO (Government Accountability Office). 2004. VA and DOD health care: Resource sharing at selected sites. Report to the chairman, Subcommittee on Oversight and Investigations, Committee on Veterans’ Affairs, House of Representatives. GAO-04-792. Washington, DC: GAO. http://www.gao.gov/new.items/d04792.pdf (accessed January 27, 2012). GAO. 2006. VA health care: Experiences in Denver and Charleston offer lessons for future partnerships with medical affiliates. GAO-06-472. Washington, DC: GAO. http://www. gao.gov/new.items/d06472.pdf (accessed January 27, 2012). GAO. 2007. VA health care: VA should better monitor implementation and impact of capi- tal asset alignment decisions. Washington, DC: GAO. http://www.gao.gov/new.items/ d07408.pdf (accessed February 6, 2012). Hardin, D., and H. Ramirez. 2007. Navy Branch Health Clinic/VA Outpatient Clinic, Key West, FL. Presentation by LCDR Dawn Hardin, BHC Key West, and Dr. Hector Ramirez, VA Key West. 2007 Joint Venture Conference. http://www.tricare.mil/DVPCO/el-paso/ Key%20West%20VA%20Joint%20Venture%20Conference%202007.ppt (accessed Feb- ruary 16, 2012). Hite, R. 2011. Personal communication with Robert Hite, Program Manager, Policy, Reports and Analysis, DoD VA Program Coordination Office, Office of the Assistant Secretary of Defense (Health Affairs), October 25. Horner, B., and J. Holes. 2007. Tripler joint venture update. Presentation by Ms. Brenda Horner and Mr. John Holes. 2007 Joint Venture Conference, March 6. http://www. tricare.mil/DVPCO/el-paso/Tripler%20JV%20Conference%202007%20v3.ppt (ac- cessed November 7, 2011). Horner, B., and J. Holes. 2008. Tripler Army Medical Center and VA Pacific Islands Health Care System. Presentation by Brenda J. Horner and John E. Holes. 2008 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20 -%20Hawaii%20JV%20(TAMC-VAPIHCS).ppt (accessed November 7, 2011). Horner, B., and J. Holes. 2009. Hawaii collaboration. Presentation by Ms. Brenda Horner, Tripler Army Medical Center, and Mr. John E. Holes, VA Pacific Islands Health Care System. Power of DoD/VA Sharing Conference, June 3. Horner, B., E. Camara, and R. Girton. 2006. DoD/VA joint venture: Joint Venture Incentive Fund proposals. Presentation by project managers Brenda Horner (TAMC) and Dr. Enrico Camara and Dr. Richard Girton (VAPIHCS). 2006 Joint Venture Conference, February. www.tricare.mil/DVPCO/bummed/Tripler.ppt (accessed November 7, 2011). Irwin, D., and K. Drew. 2008. Elements of a joint venture. Presentation by Ms. Debra Irwin, Chief, DoD/VA Resource Sharing, Air Force Surgeon General’s Office, and Ms. Kendra Drew, Director, VA/DoD Medical Sharing Office, Veterans Health Administration. 2008 Joint Venture Conference. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20 Conf%20-%20Elements%20of%20a%20JV.ppt (accessed December 7, 2011).

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220 LOVELL FEDERAL HEALTH CARE CENTER MERGER Johnson, J. R., R. Lockhart, and D. E. Stoops. 2009. Gulf Coast Joint Ambulatory Care Clinic (JACC). Success stories on sharing: Joint clinics. Presentation by Mr. J. Ronald Johnson, FACHE, Mr. Ralph Lockart, and Mr Dennis E. Stoops. VA/DoD Sharing Con- ference, June 2–4. http://www.tricare.mil/DVPCO/SharingConf.cfm (accessed November 11, 2011). Joint Base Charleston. 2010. Joint basing takes pivotal step with activation of 628 ABW. http://www.charleston.af.mil/news/story.asp?id=123184751 (accessed February 6, 2012). Joint Venture Review. 2011. Charleston-Beaufort: Joint venture review: Naval Health Clinic Charleston; Ralph H. Johnson Veterans Affairs Medical Center; 628 Medical Group, Joint Base Charleston; Naval Hospital Beaufort. 2011 VA/DoD Joint Venture Con- ference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Charleston Joint Venture] (ac- cessed January 26, 2012). Keesler Air Force Base. 2011. 81st Medical Group. http://www.keesler.af.mil/library/factsheets/ factsheet.asp?id=4972 (accessed December 14, 2011). Kolenc, V. 2012. The new Beaumont Army Medical Center: Contractors can benefit from Fort Bliss’ $1B project. El Paso Times, August 13. http://www.elpasotimes.com/ci_21298898/ contractors-can-benefit-from-fort-bliss-1b-project (accessed September 5, 2012). Kyte, R., and E. Camara. 2006. DoD/VA joint venture: Joint venture demonstration project. Presentation by project managers Rosemary Kyte (TAMC) and Dr. Enrico Camara (VAPIHCS). 2006 Joint Venture Conference, February. www.tricare.mil/DVPCO/ bummed/Tripler.ppt (accessed November 7, 2011). Miavez, J., H. Ramirez, and D. Eaton. 2011. Naval Branch Health Clinic Key West & VA Outpatient Clinic Key West. Presentation by CAPT Julie Miavez, OIC, NBHC Key West, Dr. Hector Ramirez, ACOS, Ambulatory Care VA Miami, and Dr. Douglas Eaton, CMO, VA Key West. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/ CJVC2011.cfm [Key West Joint Venture] (accessed February 16, 2012). Mietzner, D., and D. Gerrard. 2009. The Mike O’Callaghan Federal Hospital. Presenta- tion by Col. David Mietzner and Dan Gerrard. 2009 Joint Venture Conference. http:// www.tricare.mil/DVPCO/downloads/20090625/Breakout7bJVUpdateMikeOCallaghan FedHospitalNV.ppt (accessed January 6, 2012). Militarynewcomers.com. 2012. Naval Weapons Station Charleston. Health care. http://www. militarynewcomers.com/NWSCHARLESTON/resources/05_health.html (accessed Janu- ary 26, 2012). MOFH (Mike O’Callaghan Federal Hospital). 2006. The Mike O’Callaghan Federal Hospi- tal. Presentation at 2006 Joint Venture Conference, February. www.tricare.mil/DVPCO/ bummed/Nevada.ppt (accessed January 5, 2012). MOFH. 2007. Presentation on Mike O’Callaghan Federal Hospital (MOFH), March 2007, Nellis AFB, NV. 2007 Joint Venture Conference, March. http://www.tricare.mil/DVPCO/ el-paso/Nellis%20Joint%20Venture%20Slides%202007c.ppt (accessed January 5, 2012). Morro, M., D. Wyman, and K. Fogarty. 2009. Gulf Coast joint VA/DoD healthcare network “center(s) of excellence.” Presentation by CAPT Maryalice Morro, BG Daniel Wyman, and Ms. Kathleen Fogarty. VA/DoD Sharing Conference, June 2–4. http://www.tricare. mil/DVPCO/SharingConf.cfm (accessed November 11, 2011). Mosher, P., J. Majerle, and L. Kelly. 2009. Success stories on sharing: Clinical applications (hemodialysis & neurosurgery). Presentation by Peter Mosher, DGMC, John Majerle, VANCHCS, and Laura Kelly, VISN 21. The Power of DoD/VA Sharing Conference, June 4. http://www.tricare.mil/DVPCO/downloads/20090625/Breakout6aSuccessStories ClinicalApplicationsNeurosurgeryDialysisClinicsFairfieldCA.ppt (accessed December 7, 2011).

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APPENDIX C 221 MUSC (Medical University of South Carolina). 2012. Ralph H. Johnson Veteran’s Administra- tion Medical Center. http://academicdepartments.musc.edu/research/ord/collab_proposal/ institutional_boilerplate/clinical/va.html (accessed September 5, 2012). NBHC (Naval Branch Health Clinic). 2012. Key West Branch Health Clinic. http://www. med.navy.mil/sites/NavalHospitalJAX/AboutUs/Pages/Keywest.aspx (accessed February 16, 2012). NBHC Corry Station/JACC. 2011. Corry Station. http://www.med.navy.mil/sites/pcola/Na- vyBranchHealthClinics/CorryStation/Pages/default.aspx (accessed November 9, 2011). Nellis Air Force Base. 2012. Medical services. http://www.nellis.af.mil/library/factsheets/ factsheet.asp?id=4073 (accessed January 8, 2012). Nicholson, R. J. 2005a. Prepared statement of Hon. James Nicholson, Secretary, Department of Veterans Affairs. Proposed fiscal year 2006 budget for Department of Veterans Affairs programs. Hearing before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 109-72, February 15. Washington, DC: U.S. Government Printing Office. http://frwe- bgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_senate_hearings&docid=f:22412. pdf (accessed January 3, 2012). Nicholson, R. J. 2005b. Statement of the Honorable R. James Nicholson, Secretary, Depart- ment of Veterans Affairs. Department of Veterans Affairs budget request for FY 2006. Hearing before the Committee on Veterans’ Affairs, House of Representatives, February 16. Serial No. 109-1. Washington, DC: U.S. Government Printing Office. http://frwebgate. access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_house_hearings&docid=f:20426.pdf (ac- cessed January 5, 2012). Pacific Region Health Systems. 2011. http://virtual.mybaseguide.com/military/army/ tripler/#page68I (accessed November 3, 2011). Panangala, S. V. 2005. Veterans health care issues in the 109th Congress. CRS report for Congress, June 24. Order Code RL32961. Washington, DC: Congressional Research Service. http://www.policyarchive.org/handle/10207/bitstreams/2477.pdf (accessed Janu- ary 3, 2012). Pendergrass, S. 2010. Statement of Dr. Susan Pendergrass, Director, VA Northwest Network (VISN 20), Veterans Health Administration, Department of Veterans Affairs, before the Committee on Veterans’ Affairs, United States Senate, Field Hearing in Fairbanks, Alaska. http://veterans.senate.gov/hearings.cfm?action=release.display&release_id=73308297- 1724-4e95-b725-84a067127c9d (accessed November 29, 2011). Perdue, R., and M. Ancker. 2007. ELPVAHCS-WBAMC update. Presentation by Ray Per- due and Mary Ancker. 2007 VA/DoD Joint Venture Conference. http://www.tricare. mil/DVPCO/el-paso/El%20Paso%20JV%20Update%202007.ppt (accessed February 9, 2012). Perdue, R., and M. Ancker. 2011. El Paso joint venture update. Presentation by Ray Per- due and Mary Ancker. 2011VA/DoD Joint Venture Conference. http://www.tricare.mil/ DVPCO/El-Paso.cfm [El Paso Joint Venture Update] (accessed February 9, 2012). Perlin, J. B. 2006. Testimony of Hon. Jonathan B. Perlin, MD, PhD, Under Secretary for Health, Department of Veterans Affairs. Field hearing on the state of VA care in Hawaii: Part II. Hearing before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 109-376, January 11. Washington, DC: U.S. Government Printing Office. http://ftp. resource.org/gpo.gov/hearings/109s/27351.txt (accessed January 5, 2012).

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222 LOVELL FEDERAL HEALTH CARE CENTER MERGER Perlin, J. B. 2007. Statement of Jonathan B. Perlin, MD, PhD, MSHA, FACP, Under Secretary for Health, Department of Veterans Affairs. Department of Veterans Affairs collabora- tion opportunities with affiliated medical institutions and the DOD. Hearing before the Committee on Veterans’ Affairs, House of Representatives, March 8, 2006. Serial No. 109-37. Washington, DC: U.S. Government Printing Office. http://frwebgate.access. gpo.gov/cgi-bin/getdoc.cgi?dbname=109_house_hearings&docid=f:26675.pdf (accessed January 27, 2012). Perera, D. 2011. iEHR will be in place 4 to 6 years from now, says Baker. Fierce Government, May 31. http://www.fiercegovernmentit.com/story/iehr-will-be-place-4-6-years-now-says- baker/2011-05-31 (accessed November 8, 2011). Principi, A. J. 1999. Verbal testimony of Anthony J. Principi. To receive the report of the Con- gressional Commission on Servicemembers and Veterans Transition Assistance. Hearing before the Committee on Veterans’ Affairs, House of Representatives, February 23. Serial No. 106-2. Washington, DC: U.S. Government Printing Office. http://frwebgate.access. gpo.gov/cgi-bin/getdoc.cgi?dbname=106_house_hearings&docid=f:56375.pdf (accessed January 3, 2012). Roadman, C., II. 1999. Statement of Lt. Gen. Charles Roadman, II, Surgeon General, United States Air Force. Department of the Air Force presentation on the Defense Health Program to the Committee on Armed Services Subcommittee on Personnel, United States Senate, March 11. http://armed-services.senate.gov/statemnt/1999/990311cr.pdf (accessed January 17, 2012). Robb, D. J., and C. Sepich. 2008. Gulf Coast joint VA/DoD healthcare network “center(s) of excellence.” Presentation by BG Douglas J. Robb, Commander, 81st Medical Group, Keesler AFB, and Mr. Charles Sepich, Director, VA Gulf Coast Veterans Healthcare System. 2008 VA/DoD Joint Venture Conference, March 4–6. http://www.tricare.mil/ DVPCO/Hawaii/2008%20JV%20Conf%20-%20Gulf%20Coast%20Healthcare%20 Network.ppt (accessed December 13, 2011). Robinson, A. M., Jr. 2011. Prepared statement of Vice Admiral Adam M. Robinson, Jr. De- fense Health Program FY12 budget. Hearing before the Subcommittee on Defense of the Senate Committee on Appropriations, April 6. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2012_sapp_ def_3&docid=f:99104433.pdf (accessed January 27, 2012). Rogers, B. 2007. Albuquerque joint venture. Presentation by Ben Rogers, CHE, NMVAHCS Joint Venture Director. 2007 Joint Venture Conference, March 8. http://www.tricare.mil/ DVPCO/el-paso/JV%20ConfAlbuquerque.ppt (accessed January 17, 2012). Sanders, J. 2012. VA medical center opens, keeps strong ties to Mike O’Callaghan. 99th Air Base Wing Public Affairs, Nellis Air Force Base. http://www.nellis.af.mil/news/story. asp?id=123315628 (accessed September 5, 2012). Scharenbrock, C., and K. C. Carlson. 2010. Joint venture partnership successes, VANCHCS & Tribal Entities, DGMC & VANCHCS. Presentation by Dr. Christopher Scharenbrock, David Grant USAF Medical Center, and K. C. Carlson, VA Northern California Health Care System, January. Simmons, J. 1989. Integrating federal health care resources at the local level. Hospital & Health Services Administration 34(1):113–122. Spaulding, S., and K. L. Catton. 2008. Albuquerque joint venture. Presentation by Scott Spaulding, 377th Medical Group, and Kara L. Catton, New Mexico VAHCS. 2008 VA/ DoD Joint Venture Conference, March. http://www.tricare.mil/DVPCO/Hawaii/2008%20 JV%20Conf%20-%20Albuquerque%20JV%20(377MDG-NMVAHCS).ppt (accessed January 17, 2012).

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APPENDIX C 223 Spector, A., and B. Cecil. 2008. Alaska. Presentation by Mr. Alex Spector, VA Director, and Colonel Billy Cecil, 3MDG Deputy Commander. 2008 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/Hawaii/2008%20JV%20Conf%20-%20 Alaska%20JV%20(3MDG-VAHCS).ppt (accessed October 31, 2011). U.S. Congress. 2003. H.R. 1720, to authorize the Secretary of Veterans Affairs to carry out construction projects for the purpose of improving, renovating, establishing, and updat- ing patient care facilities at Department of Veterans Affairs medical centers, to provide by law for the establishment and functions of the Office of Research Oversight in the Veterans Health Administration of the Department of Veterans Affairs, and for other purposes. http://www.gpo.gov/fdsys/pkg/BILLS-108hr1720rfs/pdf/BILLS-108hr1720rfs. pdf (accessed January 27, 2012). U.S. Senate. 1980. Hearing before the Committee on Governmental Affairs, United States Senate, Ninety-sixth Congress, Second Session, on S. 2958, Federal Interagency Medical Resources Sharing and Coordination Act of 1980, July 30. http://babel.hathitrust.org/ cgi/pt?id=mdp.39015083099906 (accessed February 23, 2012). VA. 2002. Health care sharing by the Department of Veterans Affairs and Department of Defense. Staff report to the House Committee on Veterans’ Affairs, February 25. Hearing before the Health Subcommittee of the Committee on Veterans’Affairs and the Military Personnel Subcommittee of the Committee on Armed Services, House of Representatives, March 7. Washington, DC: U.S. Government Printing Office. http://frwebgate.access. gpo.gov/cgi-bin/getdoc.cgi?dbname=107_house_hearings&docid=f:80528.pdf (accessed January 27, 2012). VA. 2003. Departments of Veterans Affairs and Housing and Urban Development, and inde- pendent agencies appropriations for fiscal year 2004. Hearings before the Subcommittee of the Committee on Appropriations, March 13. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2004_sapp_ va_1&docid=f:1910401.pdf (accessed January 3, 2012). VA. 2006. Hearing on construction and lease authorization needs of the Department of Veterans Affairs. Hearing before the Committee on Veterans’ Affairs, United States Senate, S. Hrg. 109-561, April 6. Washington, DC: U.S. Government Printing Office. http://frwebgate. access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_senate_hearings&docid=f:28176.pdf (ac- cessed January 5, 2012). VA. 2007a. The VA’s budget request for fiscal year 2007. Hearing before the Committee on Veterans’ Affairs, House of Representatives, February 8. Serial No. 109-30. Washington, DC: U.S. Government Printing Office. http://frwebgate.access.gpo.gov/cgi-bin/getdoc. cgi?dbname=109_house_hearings&docid=f:26103.pdf (accessed January 5, 2012). VA. 2007b. VA handbook 0311. Appendix C (p. C-3). November 8. http://www1.va.gov/ vapubs/viewPublication.asp?Pub_ID=381&FType=2 (accessed January 5, 2012). VA. 2008. VA FY 2008 Congressional budget submission, Vol. III, Construction. http://www. va.gov/budget/products.asp [FY 2008 Budget Submission] (accessed January 6, 2012). VA. 2011a. VA Gulf Coast Veterans Health Care System. http://www.biloxi.va.gov/about/ (accessed December 14, 2011). VA. 2011b. VA Gulf Coast: Joint venture review. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Keesler Joint Venture] (accessed No- vember 11, 2011). VA. 2011c. VA Gulf Coast: Joint venture review. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Keesler Joint Venture] (accessed No- vember 11, 2011). VA. 2011d. VA Gulf Coast Veterans Health Care System. http://www.biloxi.va.gov/visitors/ Pensacola.asp (accessed November 9, 2011).

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224 LOVELL FEDERAL HEALTH CARE CENTER MERGER VA. 2012a. Alaska VA Healthcare System, Fairbanks, Alaska, Community-Based Outpatient Clinic. http://www.alaska.va.gov/visitors/fairbanks.asp (accessed April 27, 2012). VA. 2012b. El Paso VA Health Care System. http://www2.va.gov/directory/guide/facility. asp?ID=46 (accessed February 10, 2012). VA. 2012c. Miami VA Healthcare System: Locations. Key West Outpatient Clinic. http://www. miami.va.gov/locations/KeyWest.asp (accessed February 16, 2012). VA. 2012d. New VA medical center with state-of-the-art mental unit to open in Las Vegas. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2363 (accessed September 27, 2012). VA. 2012e. Ralph H. Johnson VA Medical Center. About this facility. http://www.charleston. va.gov/about (accessed January 26, 2012). VA/DoD. 1995. Hearing on VA/DoD sharing before the Subcommittee on Hospitals and Health Care, Committee on Veterans’ Affairs, House of Representatives, October 18. http://democrats.veterans.house.gov/hearings/schedule104/transcript104/sn104-12.htm (accessed January 3, 2012). VA/DoD. 2000. VA/DoD health care sharing. Hearing before the Subcommittee on Health of the Committee on Veterans’ Affairs, House of Representatives, May 17. Serial No. 106-39. Washington, DC: U.S. Government Printing Office. http://frwebgate.access. gpo.gov/cgi-bin/getdoc.cgi?dbname=106_house_hearings&docid=f:66495.pdf (accessed December 5, 2011). VA/DoD. 2002. Department of Veterans Affairs and Department of Defense health resources sharing: Staff report. Committee on Veterans’ Affairs, U.S. House of Representatives, February 25. Washington, DC: U.S. Government Printing Office. http://veterans.house. gov/sites/republicans.veterans.house.gov/files/documents/vadodsha.pdf (accessed Febru- ary 9, 2012). VA/DoD. 2006. VA/DoD joint venture: Wm Beaumont Army Medical Center and El Paso VA Health Care System. Presentation at 2006 Joint Venture Conference, February. www. tricare.mil/DVPCO/bummed/ElPaso.ppt (accessed February 9, 2012). VA/DoD. 2007. VA/DoD Joint Executive Council FY 2006 annual report. February. http:// www.tricare.mil/DVPCO/downloads/VADoD2006.pdf (accessed November 7, 2011). VA/DoD. 2008a. VA/DoD Joint Executive Council fiscal year 2007 annual report. Febru- ary. http://www.tricare.mil/DVPCO/downloads/VA%20DoD%202007%20Annual%20 Report%20FINAL%203-14-08.pdf (accessed December 13, 2011). VA/DoD. 2008b. VA/DoD Joint Executive Council FY 2008 annual report, including 2009– 2011 joint strategic plan. http://www.tricare.mil/DVPCO/downloads/VA%20DoD%20 Joint%20Executive%20Council%20Annual%20Report.pdf (accessed November 8, 2011). VA/DoD. 2009a. VA/DoD Joint Executive Committee FY 2009 annual report: Joint strategic plan 2010–2012. http://prhome.defense.gov/docs/2009%20VA%20DoD%20Joint%20 Executive%20Council%20Annual%20Report%20and%20Joint%20Strategic%20Plan. pdf (accessed November 8, 2011). VA/DoD. 2009b. VA/DoD Joint Executive Council FY 2008 annual report, including 2009– 2011 joint strategic plan. VA/DoD. 2010. VA/DoD Joint Executive Council annual report for FY 2010. http://www. tricare.mil/DVPCO/downloads/2010%20JEC%20Annual%20Report%20to%20 Congress%20(signed).pdf (accessed January 27, 2012). VA/DoD. 2011a. Mike O’Callaghan Federal Hospital briefing. 2011 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/CJVC2011.cfm [Las Vegas Joint Venture] (accessed January 3, 2012). VA/DoD. 2011b. New Mexico VA Health Care System, 377th Medical Group, Kirtland AFB, Albuquerque, NM. 2011 VA/DoD Joint Venture Conference. http://www.tricare. mil/DVPCO/CJVC2011.cfm [Albuquerque Joint Venture] (accessed January 17, 2012).

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APPENDIX C 225 Wilder, D., and L. Kelly. 2011. Personal communication and discussion with the IOM Com- mittee on Evaluation of the Lovell Federal Health Care Center Merger. Conference call with Lt. Col. Doreen Wilder, David Grant USAF Medical Center, Travis Air Force Base, California, and Laura Kelly, VA Northern California Health Care System, in public ses- sion during the committee’s fourth meeting. Irvine, California, November 17–18. Wirtemburg, D., and M. Ancker. 2008. El Paso joint venture: Wm. Beaumont Army Medical Center and El Paso VA Health Care System. Presentation by Dane Wirtemburg, ELP- VAHCS, and Mary Ancker, WBAMC. Annual 2008 VA/DoD Joint Venture Conference. http://www.tricare.mil/DVPCO/Hawaii.cfm [El Paso Joint Venture] (accessed February 9, 2012). Wyman, D. 2010. Gulf Coast sharing success. Presentation by Brig Gen Daniel Wyman, 81 Medical Group, Keesler AFB. 2010 Military Health System Conference, January 26. http://www.health.mil/Libraries/2010_MHS_Conference_Presentations_-_Jan_26/ T06_D_Wyman.pdf (accessed December 13, 2011).

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