oversight

DOD and VA Health Care: Medication Needs during Transitions May Not Be Managed for All Servicemembers

Published by the Government Accountability Office on 2012-11-02.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Report to the Ranking Member,
                             Committee on Veterans’ Affairs,
                             House of Representatives


November 2012
                             DOD AND VA
                             HEALTH CARE
                             Medication Needs
                             during Transitions
                             May Not Be Managed
                             for All
                             Servicemembers



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GAO-13-26
                                               November 2012

                                               DOD AND VA HEALTH CARE
                                               Medication Needs during Transitions May Not Be
                                               Managed for All Servicemembers
Highlights of GAO-13-26, a report to the
Ranking Member, Committee on Veterans’
Affairs, House of Representatives




Why GAO Did This Study                         What GAO Found
Medication management is critical to           About 1 in 12 (approximately 94,000) servicemembers discharged from military
effective continuity of care for               service and Reservists and National Guard members demobilized in fiscal years
servicemembers transitioning out of            2009 through 2011 had a psychiatric or pain medication, and almost half of these
the military. Psychiatric and pain             servicemembers subsequently received care from the Department of Veterans
medications may be of particular               Affairs (VA) within 9 months. The percentage of servicemembers discharged or
concern because of potential adverse           demobilized with psychiatric or pain medications increased slightly across the
health effects if not taken as intended.       3 fiscal years, from about 7 percent in fiscal year 2009 to about 9 percent in fiscal
GAO was asked to provide information           year 2011. The most common psychiatric medications for servicemembers
on the process used by DOD and VA              discharged or demobilized from fiscal years 2009 through 2011 included
to help servicemembers manage their            antidepressants, while the most common pain medications included nonsteroidal
psychiatric and pain medications               anti-inflammatories, such as prescription-strength ibuprofen, and an opioid—
during transitions. In this report, GAO        oxycodone acetaminophen. Although not all discharged or demobilized
examined (1) the extent to which               servicemembers receive care from VA, GAO found that almost half of
servicemembers transitioned out of the         servicemembers with psychiatric or pain medications in fiscal years 2009 through
DOD health care system with                    2011 subsequently received care from VA within 9 months.
psychiatric or pain medications and
subsequently received care from VA             The Department of Defense’s (DOD) and VA’s efforts may not help all
and (2) efforts DOD and VA have in             servicemembers manage their medication needs during transitions of care. DOD
place to help ensure servicemembers’           does not have a formal policy for transitioning medication needs for all
psychiatric and pain medication needs          servicemembers, and the efforts available to all servicemembers are limited. For
are met during transitions of care. GAO        example, DOD officials identified the medical assessment as the effort DOD has
focused on active duty                         in place to help all servicemembers transition their medical needs prior to
servicemembers, Reservists, and                discharge. This assessment is a key opportunity for assisting all servicemembers
National Guard members who
                                               with managing medications; however, DOD cannot ensure that certain best
discharged from military service and
                                               practices, such as developing a plan for how to obtain medications during the
Reservists and National Guard
members who demobilized in fiscal              transition and providing current medication lists at the point of discharge, are
years 2009 through 2011. GAO also              included during these assessments. In addition to efforts that may assist all
reviewed DOD and VA documents,                 servicemembers, DOD and VA provide specific servicemember groups with more
including transition policies, and             thorough and direct assistance in transitioning their health care, including
interviewed DOD and VA officials from          medications. For example, servicemembers with complex health care needs may
headquarters and six DOD and VA                receive additional assistance through military case management services.
facilities, selected on the basis of size,     Finally, some DOD military treatment facilities and VA medical centers have
geographic location, patient                   efforts that can help manage servicemembers’ medication needs, but these may
characteristics, and other factors.            not be available at all facilities. Many of the programs available only to specific
                                               groups or to servicemembers accessing certain DOD or VA facilities incorporate
What GAO Recommends                            identified best practices for transitions of care, such as sharing medical
GAO recommends that DOD develop a              information between providers, scheduling VA appointments and providing
transition policy for medications that         servicemembers with medication lists prior to discharge. Identifying best
applies to all servicemembers and that         practices and implementing them across the departments could better ensure
DOD and VA identify and apply best             overall continuity of care, including medication management, for servicemembers
practices for managing                         transitioning between health care providers, and could reduce their potential for
servicemembers’ medication needs               adverse health effects from misusing or discontinuing psychiatric or pain
during transitions of care. DOD and VA         medications.
concurred with the recommendations.

View GAO-13-26. For more information,
contact Debra A. Draper at (202) 512-7114 or
draperd@gao.gov.

                                                                                        United States Government Accountability Office
Contents


Letter                                                                                  1
               Background                                                               5
               About 1 in 12 Transitioning Servicemembers Had Psychiatric or
                 Pain Medications; Almost Half Subsequently Received VA Care          11
               DOD’s and VA’s Efforts May Not Help All Servicemembers Manage
                 Their Medication Needs during Transitions of Care                    14
               Conclusions                                                            27
               Recommendations for Executive Action                                   28
               Agency Comments and Our Evaluation                                     28

Appendix I     Scope and Methodology                                                  31



Appendix II    Formulary Comparison                                                   35



Appendix III   Comments from the Department of Defense                                43



Appendix IV    Comments from the Department of Veterans Affairs                       45



Appendix V     GAO Contact and Staff Acknowledgments                                  49



Tables
               Table 1: Servicemembers Discharged and Reservists and National
                        Guard Members Demobilized with Psychiatric or Pain
                        Medications, Fiscal Years 2009 through 2011                   11
               Table 2: Most Common Psychiatric and Pain Medications for
                        Servicemembers Discharged and Reservists and National
                        Guard Members Demobilized, Fiscal Years 2009 through
                        2011                                                          12
               Table 3: Servicemembers Discharged and Reservists and National
                        Guard Members Demobilized with Psychiatric or Pain
                        Medications from Fiscal Years 2009 through 2011 Who
                        Subsequently Received Care from VA                            13




               Page i                                     GAO-13-26 DOD and VA Health Care
          Table 4: Comparison of DOD’s and VA’s Formularies for
                   Psychiatric and Pain Medications, March 2012                                     37


Figures
          Figure 1: DOD and VA Efforts Available to All Servicemembers
                   That May Help Servicemembers Manage Their
                   Medications during Transitions of Care                                           15
          Figure 2: DOD and VA Efforts Targeted to Specific Servicemember
                   Groups That Provide Additional Assistance to Help
                   Manage Medication Needs during Transitions of Care                               20




          Abbreviations

          DOD               Department of Defense
          OEF               Operation Enduring Freedom
          OIF               Operation Iraqi Freedom
          OND               Operation New Dawn
          PTSD              post-traumatic stress disorder
          VA                Department of Veterans Affairs
          WTU               Warrior Transition Unit


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          Page ii                                                GAO-13-26 DOD and VA Health Care
United States Government Accountability Office
Washington, DC 20548




                                   November 2, 2012

                                   The Honorable Bob Filner
                                   Ranking Member
                                   Committee on Veterans’ Affairs
                                   House of Representatives

                                   Dear Mr. Filner:

                                   Medication management—ensuring that medications are used
                                   appropriately and regimens are adhered to—is critical to effective
                                   continuity of care for those servicemembers who are transitioning out of
                                   the military and changing health care providers. Management of
                                   psychiatric and pain medications may be of particular concern because of
                                   the prevalence of the conditions for which these medications are
                                   prescribed among servicemembers and the potential adverse health
                                   effects if not taken as intended. Literature indicates that between 20 and
                                   40 percent of servicemembers returning from Operation Enduring
                                   Freedom (OEF) and Operation Iraqi Freedom (OIF) 1 suffer from
                                   deployment-related mental health conditions, including post-traumatic
                                   stress disorder (PTSD), depression, and substance abuse. 2 Mental health
                                   conditions may be managed with various therapies, including
                                   medications, such as antidepressants and antianxiety medications. Pain
                                   is a serious and highly prevalent condition, according to a report from the
                                   Department of Veterans Affairs (VA) and the Department of Defense
                                   (DOD); among returning OEF/OIF servicemembers, pain is the most
                                   frequently presented complaint. 3 Pain also may be managed with various
                                   therapies, including medications such as opioids.




                                   1
                                    Military operations in Iraq as of September 1, 2010, are referred to as Operation New
                                   Dawn (OND).
                                   2
                                    See K. H. Seal et al., “VA Mental Health Services Utilization in Iraq and Afghanistan
                                   Veterans in the First Year of Receiving New Mental Health Diagnoses,” Journal of
                                   Traumatic Stress, vol. 23, no. 1 (2010).
                                   3
                                    Department of Veterans Affairs and Department of Defense, VA/DOD Clinical Practice
                                   Guideline for Management of Opioid Therapy for Chronic Pain (May 2010).




                                   Page 1                                                  GAO-13-26 DOD and VA Health Care
Individuals may experience serious adverse health effects when
psychiatric and pain medications are abruptly discontinued. For example,
when certain psychiatric medications are abruptly discontinued, an
individual may experience problems such as relapses in psychotic
episodes, return of anxiety symptoms, and exacerbation of depression
symptoms. Similarly, when some pain medications, such as opioids, are
not gradually reduced, an individual may experience withdrawal
symptoms such as nausea, insomnia, and anxiety. Certain types of
psychiatric and pain medications should be gradually tapered off under a
doctor’s supervision.

The transition out of the DOD health care system, which can start when
servicemembers discharge from the military and continue until they are
cared for by receiving health care providers, such as VA, is a vulnerable
point in terms of providing seamless care. Transitions between health
care systems may increase the likelihood of patients deviating from their
treatment plans. Specifically, such transitions may increase the likelihood
of patients discharged with medications not adhering to their medication
regimens, for example by misusing or inappropriately discontinuing use of
a medication their providers prescribed prior to discharge.

You expressed interest in obtaining information on the process used by
DOD and VA to help servicemembers manage their psychiatric and pain
medications during transitions from DOD to VA. In this report, we provide
information on

1. the extent to which servicemembers transitioned out of the DOD
   health care system with psychiatric or pain medications and
   subsequently received care from VA and
2. the efforts DOD and VA have in place to help ensure
   servicemembers’ psychiatric and pain medication needs are met
   during transitions of care.

As requested, we also compared DOD’s and VA’s formularies for
psychiatric and pain medications. (See app. II.)

To determine the extent to which servicemembers transitioned out of the
DOD health care system with psychiatric or pain medications and
subsequently received care from VA, we obtained data from DOD’s




Page 2                                        GAO-13-26 DOD and VA Health Care
Defense Manpower Data Center and Defense Health Cost Assessment
and Program Evaluation on the number of servicemembers who were
discharged from military service 4 and Reservists and National Guard
members who were demobilized with psychiatric or pain medications
(prescribed prior to discharge or demobilization) in fiscal years 2009,
2010, and 2011. 5 In this report, we included servicemembers who
discharged—active duty servicemembers, Reservists, and National
Guard members—and Reservists and National Guard members who
demobilized, because both of these populations can transition out of the
DOD health care system and could be eligible for VA care. We then
obtained data from VA’s National Data System on how many of these
servicemembers subsequently received health care from VA within
9 months of their discharge or demobilization date. We selected the
9-month time frame to provide consistent data across each of the 3 fiscal
years—the most current available VA data at the time of our review were
from June 2012, 9 months after the end of fiscal year 2011. Data on
servicemembers who subsequently received care from VA do not
describe the full population of servicemembers who received care after
being discharged from military service or demobilized as not all
servicemembers subsequently seek and receive care from VA. We
assessed the reliability of the data in several ways, including discussing
with DOD and VA officials their methodology and data-collection
techniques and conducting our own review of their programming and
methodological approaches using data file documentation, code book and
file dictionaries, and programming logs.

To identify the efforts DOD and VA have in place to help ensure
servicemembers’ psychiatric and pain medication needs are met during
transitions of care, we reviewed documents and interviewed officials from
DOD, the Department of the Army, 6 and VA. We reviewed documents,
such as department policies related to health care and medication
transitions. We interviewed officials from DOD, Army, and VA



4
 Servicemembers may discharge from the military under several circumstances, including
expiration of term of service, medical retirement, and career retirement.
5
 The number of servicemembers with pain or psychiatric medications is not equivalent to
the number of servicemembers with related conditions because psychiatric and pain
medications may be prescribed for other conditions.
6
 We focused our review on the Army, rather than other military service branches, because
the Army has the largest number of OEF/OIF/OND servicemembers.




Page 3                                                GAO-13-26 DOD and VA Health Care
headquarters offices that have oversight of, and set policies related to,
the provision of health care, including psychiatric and pain care and
prescription medication benefits, and that have roles in assisting
servicemembers with their health care as they transition out of DOD. For
example, we interviewed officials from DOD’s TRICARE Management
Activity’s Clinical Quality Office, Pharmacoeconomic Center, and Case
Management Program; and the Office of the Surgeon General of the
Army. We also interviewed officials from VA’s VA/DOD Collaboration
Office and the Veterans Health Administration’s Pharmacy Benefits
Management Services, Liaisons for Healthcare Program, and
OEF/OIF/OND Care Management Program. In addition, we interviewed
officials, including providers and case managers, from local Army military
treatment facilities and VA medical centers, as well as servicemembers
and veterans, through six site visits. We selected sites to visit to obtain a
diverse sample on the basis of criteria such as facility size, patient
complexity, presence or absence of a VA Liaison for Healthcare, and
Army and VA region, and to ensure military treatment facility proximity to
a VA medical center. On the basis of these criteria we selected the
following facilities: (1) Walter Reed National Military Medical Center
(Bethesda, Md.); (2) Washington D.C. VA Medical Center; (3) Bayne-
Jones Army Community Hospital (Fort Polk, La.); (4) Alexandria VA
Medical Center (Pineville, La.); (5) Weed Army Community Hospital (Fort
Irwin, Calif.); and (6) Loma Linda (Calif.) VA Medical Center. Finally, we
interviewed officials from selected veterans service organizations—the
American Legion, Military Officers Association of America, and Wounded
Warrior Project—to obtain their perspectives on transition policies and
programs.

We focused our review on efforts that department officials and local
military treatment facility and VA medical center officials identified as
having a role in helping servicemembers manage their medications as
they transition from DOD to VA. We also focused on the transition efforts
used by servicemembers transitioning between outpatient settings, rather
than inpatient settings, because medication management between
outpatient settings is a vulnerable point in terms of providing seamless
care. The transition efforts we identified may not be exhaustive because
some servicemembers may have received help through efforts that were
not identified by the officials we interviewed or through efforts that may
not have been related to the health care aspects of their transition. We
did not review the effectiveness of the efforts identified.




Page 4                                         GAO-13-26 DOD and VA Health Care
             Additionally, we reviewed relevant literature on transitions of care and
             medication adherence, including effective approaches for transitioning
             health care needs and strategies for promoting patient adherence to
             medication treatment plans. For example, we reviewed literature from the
             National Transitions of Care Coalition, a nonprofit organization that works
             to address gaps that affect safety and quality of care for transitioning
             patients, to identify best practices within DOD’s and VA’s transition
             efforts.

             We conducted this performance audit from January 2012 to October 2012
             in accordance with generally accepted government auditing standards.
             Those standards require that we plan and perform the audit to obtain
             sufficient, appropriate evidence to provide a reasonable basis for our
             findings and conclusions based on our audit objectives. We believe that
             the evidence obtained provides a reasonable basis for our findings and
             conclusions based on our audit objectives. See appendix I for a complete
             description of our scope and methodology.


             DOD and VA provide health care, including medications for psychiatric
Background   and pain conditions, to servicemembers and veterans through their
             respective health care systems. Due to concerns about the continuity of
             care for servicemembers transitioning between the two health care
             systems, the departments have made efforts to coordinate transitions of
             care from DOD to VA. Medication management is a key component of
             transitions of care, and although servicemembers may misuse or
             discontinue their use of medications at any time, including while they are
             under a provider’s care, literature suggests there is greater risk for these
             issues during transition periods. 7




             7
              See for example, E. A. Coleman, et al., “The Care Transitions Intervention: results of a
             randomized controlled trial,” Archives of Internal Medicine, vol. 166, no. 17 (2006).




             Page 5                                                  GAO-13-26 DOD and VA Health Care
DOD Health Care   DOD provides health care to active duty servicemembers; Reservists and
                  National Guard members on active duty; 8 and other beneficiaries, such as
                  family members and retired servicemembers. Through TRICARE and a
                  direct-care system of military treatment facilities operated by the
                  Departments of the Army, Navy, and Air Force, DOD offers
                  comprehensive health care coverage, including outpatient and inpatient
                  care, preventive care, prescription medication coverage, and mental
                  health care. 9 Beneficiaries also can obtain care from civilian health care
                  providers.

                  TRICARE beneficiaries may obtain prescription medications through
                  military treatment facility pharmacies, network and nonnetwork retail
                  pharmacies, and the TRICARE mail-order pharmacy. DOD is required by
                  law to make all clinically appropriate medications available to
                  servicemembers, and, with the exception of several classes of
                  medications, such as smoking-cessation and weight-loss medications,
                  DOD makes all Food and Drug Administration-approved medications
                  available. 10 DOD’s formulary includes a list of medications that all military
                  treatment facilities must provide and a list of medications that military
                  treatment facilities may elect to provide on the basis of the types of
                  services offered at that facility (e.g., cancer medications). 11 DOD also can
                  classify medications “nonformulary” on the basis of its evaluation of their
                  cost and clinical effectiveness. Nonformulary medications are available to
                  beneficiaries at a higher cost, unless the provider can establish medical
                  necessity.

                  When discharging or demobilizing, some servicemembers are eligible for
                  transitional health care benefits through TRICARE. For example, the
                  Transitional Assistance Management Program provides 180 days of



                  8
                   Reservists and National Guard members on active duty for more than 30 days are
                  covered by TRICARE. They also may be eligible for TRICARE coverage prior to active
                  duty and after active duty and may be eligible to purchase TRICARE coverage when they
                  return to inactive status. See GAO, Defense Health Care: DOD Lacks Assurance That
                  Selected Reserve Members Are Informed about TRICARE Reserve Select, GAO-11-551
                  (Washington, D.C.: June 3, 2011).
                  9
                  According to DOD, as of September 2012, there were 244 military treatment facilities.
                  10
                      See 10 U.S.C. § 1074g(a)(3); 32 C.F.R. §§ 199.4(g), 199.21(h)(3)(iii).
                  11
                    A formulary is a list of medications, grouped by medication class, that a health care
                  system’s providers are expected to use when prescribing medications.




                  Page 6                                                   GAO-13-26 DOD and VA Health Care
                 benefits to certain eligible servicemembers, including Reservists and
                 National Guard members. 12 These servicemembers could therefore be
                 eligible for both DOD and VA health care during this period. 13


VA Health Care   Veterans who served in active military duty and who were discharged or
                 released under conditions other than dishonorable are generally eligible
                 for VA health care. 14 Reservists and National Guard members also may
                 be eligible for VA health care if they were called to active duty by a
                 federal order and completed the full period for which they were called.
                 Reservists and National Guard members also can be eligible for VA
                 health care when they demobilize from combat operations, even if they
                 have not separated from military service. In general, veterans must enroll
                 in VA health care to receive VA’s medical benefits package—a set of
                 services that includes a full range of hospital and outpatient services,
                 prescription medications, and noninstitutional long-term care services. 15
                 VA provides health care services at various types of facilities, including
                 VA medical centers. 16

                 Veterans may obtain prescription medications through VA’s mail-order
                 pharmacy and medical center pharmacies. VA has a national formulary
                 that provides access to medications for eligible beneficiaries. VA makes



                 12
                   Reservists and National Guard members can transition from DOD health care both
                 when they discharge from the military, under circumstances such as retirement, and when
                 they separate from active duty.
                 13
                   Similarly, retired servicemembers also could be eligible for both TRICARE and VA
                 benefits.
                 14
                   Any veteran who has served in a combat theater after November 11, 1998, including
                 OEF/OIF/OND veterans, and who was discharged or released from active military duty on
                 or after January 28, 2003, has up to 5 years from the date of the veteran’s most recent
                 discharge or release from active duty service to enroll in VA’s health care system and
                 receive VA health care services. See 38 U.S.C. § 1710(e)(1)(D),(e)(3). For those veterans
                 who do not enroll during their enhanced eligibility period, eligibility for enrollment and
                 subsequent care is based on other factors such as compensable service-connected
                 disability, VA pension status, catastrophic disability determination, or financial
                 circumstances.
                 15
                   VA’s enrollment system includes eight categories for enrollment, with priority generally
                 based on service-connected disability, low income, and other recognized statuses such as
                 former prisoners of war. See 38 U.S.C. § 1705; 38 C.F.R. § 17.36.
                 16
                  According to VA, as of June 2012, there were 152 medical centers.




                 Page 7                                                 GAO-13-26 DOD and VA Health Care
                      decisions about whether to add medications to its formulary on the basis
                      of clinical and cost effectiveness and, like DOD, provides access to
                      nonformulary medications when a physician attests that there is a
                      compelling clinical reason to do so through its nonformulary request
                      process. 17 Veterans also may receive health care funded by sources
                      other than VA, including private insurance, Medicare, and Medicaid.


Transitions of Care   The process and length of time for transitioning servicemembers’ health
                      care from DOD to VA or another health care system varies. For instance,
                      some servicemembers separate from the military and have their first
                      appointment at VA the following week. Others may take more time to
                      transition to VA, waiting months or years before scheduling their first
                      appointment. Furthermore, some servicemembers may not transition their
                      care to VA at all and instead seek care from other health care providers.

                      As GAO has previously reported, DOD and VA have created a number of
                      clinical and nonclinical programs to assist servicemembers during
                      transitions between the two departments. 18 For example, to improve case
                      management during transitions, 19 there are programs such as Army
                      Warrior Transition Units (WTU) 20 and the VA OEF/OIF/OND Care


                      17
                        Each VA medical center is responsible for establishing a process to adjudicate
                      nonformulary medication requests that ensures decisions are evidence-based in
                      accordance with certain prescribing criteria. Medical centers are required to adjudicate
                      nonformularly medication requests within 96 hours.
                      18
                        GAO, DOD and VA Health Care: Federal Recovery Coordination Program Continues to
                      Expand but Faces Significant Challenges, GAO-11-250 (Washington, D.C.: Mar. 23,
                      2011); VA and DOD Health Care: Progress Made on Implementation of 2003 President’s
                      Task Force Recommendations on Collaboration and Coordination, but More Remains to
                      Be Done, GAO-08-495R (Washington, D.C.: Apr. 30, 2008); DOD and VA: Preliminary
                      Observations on Efforts to Improve Health Care and Disability Evaluations for Returning
                      Servicemembers, GAO-07-1256T (Washington, D.C.: Sept. 26, 2007); DOD and VA
                      Outpatient Pharmacy Data: Computable Data Are Exchanged for Some Shared Patients,
                      but Additional Steps Could Facilitate Exchanging These Data for All Shared Patients,
                      GAO-07-554R (Washington, D.C.: Apr. 30, 2007).
                      19
                        According to the Case Management Society of America, case management is a
                      collaborative process of assessment, planning, facilitation, and advocacy for options and
                      services to meet an individual’s health needs through communication and available
                      resources to promote quality cost-effective outcomes.
                      20
                        WTUs provide a comprehensive program of medical care, rehabilitation, professional
                      development, and personal goals for wounded, ill, and injured servicemembers to help
                      them remain in the Army or transition to civilian life.




                      Page 8                                                  GAO-13-26 DOD and VA Health Care
                         Management Program. 21 DOD and VA also have longstanding efforts to
                         improve the two departments’ health information exchange capabilities.
                         For exchanging health information, the departments have relied on a
                         patchwork of initiatives involving existing DOD and VA systems to
                         increase electronic health record interoperability, including an initiative to
                         share electronic health information, such as outpatient pharmacy data, on
                         separated servicemembers. GAO has reported on challenges DOD and
                         VA have faced in their data-sharing efforts—for example, challenges in
                         planning, staffing, and budgeting—and that the departments are still
                         working to overcome many of these issues. 22

                         Medication management is a key component of successful transitions of
                         care. 23 According to the National Transitions of Care Coalition—a
                         nonprofit organization that produces tools and resources to assist with
                         transitions of care—transitions should include education and counseling
                         about medication adherence, medication lists at discharge, and a plan for
                         how to get medications during transitions.


Reasons for Medication   Ensuring that patients take medications as prescribed is a challenge that
Challenges during        is well-documented in literature. Research shows that patients may not
Transitions              adhere to their prescribed medication regimens—for example by misusing
                         or inappropriately discontinuing medications. 24




                         21
                           The OEF/OIF/OND Care Management Program is located at every VA medical center
                         and provides case management services to any OEF/OIF/OND veteran who is identified
                         as high risk or who requests case management.
                         22
                           See, for example, GAO, Electronic Health Records: DOD and VA Should Remove
                         Barriers and Improve Efforts to Meet Their Common System Needs, GAO-11-265
                         (Washington, D.C.: Feb. 2, 2011); Electronic Health Records: DOD and VA Interoperability
                         Efforts Are Ongoing; Program Office Needs to Implement Recommended Improvements,
                         GAO-10-332 (Washington, D.C.: Jan. 28, 2010); and Electronic Health Records: DOD
                         and VA Have Increased Their Sharing of Health Information, but More Work Remains,
                         GAO-08-954 (Washington, D.C.: July 28, 2008).
                         23
                           Other key components of successful transitions of care include identifying a clinician to
                         coordinate patients’ transitions, coaching and education to support self-management, and
                         information sharing between providers (including a discharge summary). See National
                         Transitions of Care Coalition, Care Transition Bundle: Seven Essential Intervention
                         Categories and Crosswalk (Washington, D.C.: Feb. 28, 2011).
                         24
                           See for example, RAND, A Review of Barriers to Medication Adherence: A Framework
                         for Driving Policy Options (Santa Monica, Calif.: 2009).




                         Page 9                                                  GAO-13-26 DOD and VA Health Care
Patients can misuse their medications by taking medications in ways
other than how they were prescribed. This can include taking more than
was prescribed, for instance if a servicemember decides to increase his
or her dose of pain medication without the supervision of a physician. It
may also include cutting pills in an effort to reduce the dose or make the
prescription last longer, which can change the absorption of certain
medications such as extended-release formulations. Both of those
scenarios can potentially lead to adverse effects, including overdose and
death.

Patients may inappropriately discontinue their use of medications—
including psychiatric and pain medications—for a variety of reasons,
according to literature. 25 In particular, patients may stop taking their
medications because they do not think the medication is working; some
providers indicated this might be more likely to happen with
servicemembers who are on pain medications such as nonsteroidal anti-
inflammatory medications. Symptoms associated with a mental health
condition, such as paranoia associated with PTSD, which is prevalent
among returning servicemembers, also may make a discontinuation more
likely.

Although patients may misuse or inappropriately discontinue their use of
medications at any time, including while they are under a provider’s care,
literature suggests there is greater risk for these issues during transition
periods. For example, some servicemembers may make their health care
a lower priority when they return to their civilian responsibilities. Others
may experience delays setting up appointments with health care
providers and, as a result, discontinue use of medications.




25
 See, for example, World Health Organization, Adherence to Long-Term Therapies:
Evidence for Action (Geneva, Switzerland: 2003).




Page 10                                            GAO-13-26 DOD and VA Health Care
                                         About 1 in 12 (approximately 94,000) servicemembers discharged and
About 1 in 12                            Reservists and National Guard members demobilized from fiscal years
Transitioning                            2009 through 2011 had a psychiatric or pain medication, and almost half
                                         of these servicemembers subsequently received care from VA within
Servicemembers Had                       9 months. Both the percentage and total number of servicemembers
Psychiatric or Pain                      discharged and demobilized with psychiatric or pain medications
Medications; Almost                      increased slightly across the 3 fiscal years. Servicemembers who were
                                         discharged from military service were more likely to have psychiatric or
Half Subsequently                        pain medications than Reservists and National Guard members who
Received VA Care                         demobilized. (See table 1.)

Table 1: Servicemembers Discharged and Reservists and National Guard Members Demobilized with Psychiatric or Pain
Medications, Fiscal Years 2009 through 2011

                                                                                                      With both                Total with
                                                  With psychiatric             With pain        psychiatric and             psychiatric or
Fiscal year                            Total          medications            medications       pain medications          pain medications
2009                                407,078           12,352 (3.0%)          13,681 (3.4%)           3,914 (1.0%)             29,947 (7.4%)
2010                                407,305           13,061 (3.2%)          13,509 (3.3%)           4,169 (1.0%)             30,739 (7.5%)
2011                                378,277           15,105 (4.0%)          14,836 (3.9%)           5,127 (1.4%)             35,068 (9.3%)
                  a
Total (2009-2011)                  1,128,845          40,009 (3.5%)          41,417 (3.7%)          13,033 (1.2%)             94,459 (8.4%)
Servicemembers who
                                             b
discharged from military service   888,113            36,896 (4.2%)          34,884 (3.9%)          11,939 (1.3%)             83,719 (9.4%)
Reservists and National Guard
members who demobilized             240,732             3,113 (1.3%)          6,533 (2.7%)           1,094 (0.5%)             10,740 (4.5%)
                                         Source: GAO analysis of DOD data.

                                         Notes: Servicemembers discharged refer to active duty servicemembers, Reservists, and National
                                         Guard members who discharged from military service generally under conditions other than
                                         dishonorable.
                                         Each of the medication categories—psychiatric medications, pain medications, and both psychiatric
                                         and pain medications—is mutually exclusive. For example, a servicemember with psychiatric
                                         medications but not pain medications is counted only in the “with psychiatric medications” column. A
                                         servicemember with both psychiatric and pain medications is counted only in the “with both
                                         psychiatric and pain medications” column.
                                         Data on psychiatric and pain medications refer to prescriptions for psychiatric and pain medications
                                         that were filled, not all prescriptions that were written.
                                         a
                                          The number of servicemembers in each fiscal year does not sum to the total number of
                                         servicemembers across all 3 fiscal years because servicemembers discharged from the military or
                                         demobilized in more than 1 fiscal year are counted only once in the total.
                                         b
                                          The total number of servicemembers who discharged from military service includes 486,467 active
                                         duty servicemembers, 371,995 Reservists and National Guard members, and 29,651
                                         servicemembers who discharged from military service as both an active duty servicemember and a
                                         Reservist or National Guard member during the 3 fiscal years.




                                         Page 11                                                       GAO-13-26 DOD and VA Health Care
                                             The most common psychiatric medications for servicemembers
                                             discharged and Reservists and National Guard members demobilized
                                             from fiscal years 2009 through 2011 included sertraline (used to treat
                                             depression, PTSD, and anxiety disorders), while the most common pain
                                             medications included prescription-strength ibuprofen (used to treat mild to
                                             moderate pain) and oxycodone acetaminophen (used to treat moderate to
                                             severe pain). (See table 2.)

Table 2: Most Common Psychiatric and Pain Medications for Servicemembers Discharged and Reservists and National Guard
Members Demobilized, Fiscal Years 2009 through 2011

                                                        Percentage of total psychiatric
                                                               or pain medications at          Examples of conditions or symptoms for
Generic name (medication class)                           discharge or demobilization          which medication is commonly prescribed
Psychiatric medications
1.   Sertraline (antidepressant)                                                      12.4     Depression, PTSD, and anxiety disorders
2.   Citalopram (antidepressant)                                                      10.5     Depression
3.   Trazodone (antidepressant)                                                         7.5    Depression
4.   Buproprion (antidepressant)                                                        6.8    Depression
5.   Quetiapine (atypical antipsychotic)                                                6.0    Depression
Pain medications
1.   Ibuprofen (nonsteroidal anti-inflammatory)                                       19.0     Mild to moderate pain
2.   Naproxen (nonsteroidal anti-inflammatory)                                        12.9     Mild to moderate pain
3.   Meloxicam (nonsteroidal anti-inflammatory)                                       12.7     Mild to moderate pain
4.   Celecoxib (nonsteroidal anti-inflammatory)                                         7.4    Mild to moderate pain
5.   Oxycodone acetaminophen (opioid)                                                   7.1    Moderate to severe pain
                                             Source: GAO analysis of DOD data.

                                             Notes: Servicemembers discharged refer to active duty servicemembers, Reservists, and National
                                             Guard members who discharged from military service generally under conditions other than
                                             dishonorable.
                                             Data on psychiatric and pain medications refer to prescriptions for psychiatric and pain medications
                                             that were filled, not all prescriptions that were written.


                                             Officials stated that appropriate medication management varies across
                                             pain and psychiatric medications. For example, they noted that
                                             discontinuation of a nonsteroidal anti-inflammatory pain medication, such
                                             as ibuprofen, can typically be done by the servicemember without the
                                             supervision of a provider; patients do not typically become physically
                                             dependent on these medications and therefore these medications do not
                                             cause withdrawal symptoms when they are discontinued. In contrast,
                                             officials told us that people taking pain medications such as oxycodone
                                             acetaminophen, an opioid, for several weeks and people taking any of the
                                             psychiatric medications, including quetiapine, an antipsychotic, should


                                             Page 12                                                       GAO-13-26 DOD and VA Health Care
                                        only discontinue use of the medications under the supervision of a health
                                        care provider because of potential side effects.

                                        Although not all servicemembers who are discharged from military service
                                        or demobilized receive care from VA, we found that almost half of
                                        servicemembers with psychiatric or pain medications in fiscal years 2009
                                        through 2011 subsequently received care from VA within 9 months. (See
                                        table 3.) Among these servicemembers, the average number of days
                                        between a servicemember’s date of discharge or demobilization and first
                                        VA appointment was 81 days (about 3 months). Across the 3 fiscal years
                                        of data we reviewed, we found that about one-third of servicemembers
                                        received care at VA within 1 month.

Table 3: Servicemembers Discharged and Reservists and National Guard Members Demobilized with Psychiatric or Pain
Medications from Fiscal Years 2009 through 2011 Who Subsequently Received Care from VA

                                                                                                    With both                  Total with
                                        With psychiatric                      With pain       psychiatric and              psychiatric or
                                        medications who                 medications who      pain medications           pain medications
                          Total with      subsequently                    subsequently      who subsequently           who subsequently
                       psychiatric or     received care                   received care          received care              received care
Fiscal year         pain medications            from VA                         from VA               from VA                    from VA
2009                          29,947                     5,754                      5,418                   2,475           13,647 (45.6%)
2010                          30,739                     6,556                      5,391                   2,668           14,615 (47.5%)
2011                          35,068                     7,670                      5,680                   3,263           16,613 (47.4%)
                a
Total (2009-2011)             94,459                   19,720                      16,200                   8,311           44,231 (46.8%)
                                        Source: GAO analysis of DOD and VA data.

                                        Notes: Servicemembers discharged refer to active duty servicemembers, Reservists, and National
                                        Guard members who discharged from military service generally under conditions other than
                                        dishonorable.
                                        Data on psychiatric and pain medications refer to prescriptions for psychiatric and pain medications
                                        that were filled, not all prescriptions that were written.
                                        We limited our analysis to servicemembers who received care from VA within 9 months of discharge
                                        or demobilization to provide consistent data across each of the 3 fiscal years—the most current
                                        available data at the time of our review was from June 2012, 9 months after the end of fiscal year
                                        2011.
                                        a
                                         The number of servicemembers in each fiscal year does not sum to the total number of
                                        servicemembers across all 3 fiscal years because servicemembers discharged from the military or
                                        demobilized in more than 1 fiscal year are counted only once in the total.




                                        Page 13                                                       GAO-13-26 DOD and VA Health Care
                              Efforts DOD and VA have in place that are directed to all servicemembers
DOD’s and VA’s                are limited in their ability to help servicemembers manage their
Efforts May Not Help          medication needs during transitions of care. However, certain groups are
                              eligible for additional assistance transitioning their health care, including
All Servicemembers            medication management. Additionally, some DOD military treatment
Manage Their                  facilities and VA medical centers have efforts that can help manage
Medication Needs              servicemembers’ medication needs, but the efforts may not be available
                              at all facilities.
during Transitions of
Care
DOD and VA Efforts            DOD and VA have several efforts that may help servicemembers manage
Directed at All               their medications during transitions, but these efforts are limited in terms
Servicemembers Are            of their ability to ensure that all servicemembers have the necessary help
                              during this period. Although DOD does not have a formal policy for
Limited in Their Ability to   transitioning medication needs for all servicemembers, the two
Help Manage Transitional      departments have broader policies, programs, and procedures that
Medication Needs              provide assistance to servicemembers with aspects of their transition
                              more generally. Additionally, there are components of these efforts that
                              may help servicemembers manage their medications during the transition
                              from DOD to VA, but none of them are focused specifically on medication
                              management. These efforts can occur at several phases of the transition:
                              prior to a servicemember’s discharge from the military; during the
                              transition between the two departments; and once a veteran seeks care
                              at a VA facility. (See fig. 1.)




                              Page 14                                        GAO-13-26 DOD and VA Health Care
                     Figure 1: DOD and VA Efforts Available to All Servicemembers That May Help
                     Servicemembers Manage Their Medications during Transitions of Care




Prior to Discharge   Prior to discharge, DOD officials identified the medical assessment—an
                     interview between the discharging servicemember and a physician,
                     physician assistant, or nurse practitioner occurring prior to separation—as
                     the medical effort DOD has in place to help servicemembers transition
                     their medical needs as they discharge from the military. 26 The
                     assessment is not designed to address medication management; rather,
                     its purpose is to document servicemembers’ health at the time of
                     separation and to record injuries or illnesses incurred during military
                     service. The assessment does, however, include a review of current
                     medications. Additionally, if the health care provider conducting the
                     medical assessment believes a physical exam is appropriate, or if the




                     26
                       For Reservists and National Guard members demobilizing, the post-deployment health
                     assessment—the DOD process for assessing the medical condition of servicemembers
                     after demobilization—may identify servicemembers who need medical assistance and
                     may trigger a referral for care. Reservists and National Guard members may receive VA
                     care prior to separating from the military.




                     Page 15                                              GAO-13-26 DOD and VA Health Care
                        servicemember requests one, the servicemember will receive one—
                        commonly referred to as a separation physical. 27

                        Although the medical assessment may help servicemembers manage
                        their medications during transitions, its ability to do so is limited. First,
                        although the assessment includes a review of medications prior to
                        discharge, the assessment may not include certain best practices for
                        transitioning medication needs, such as developing a plan for how to get
                        medications during the transition and providing a medication list. Second,
                        the medical assessment and separation physical can occur up to
                        6 months before a servicemember’s separation date, and therefore may
                        not be the servicemember’s final medical appointments in the military,
                        making it difficult for the provider to counsel the servicemember on
                        medication management during the transition. Counseling about
                        medication management is a critical component of successful transitions
                        of care.

During the Transition   DOD and VA each have a telephone hotline—DOD’s Military OneSource
                        and VA’s Veterans Crisis Line—available to help servicemembers and
                        veterans with a variety of issues, including medication management.
                        Specifically, Military OneSource provides resources and information to
                        servicemembers and veterans on a range of topics—including health
                        care, education, career training, finance, and family support—and VA’s
                        Veterans Crisis Line is available for servicemembers and veterans to call
                        to connect with local VA medical centers. Although Military OneSource
                        and VA’s Veterans Crisis Line are available for servicemembers and
                        veterans to call at any time, 28 providers told us these hotlines are
                        particularly useful during transitions of care. For instance, some DOD
                        providers said they tell servicemembers to call Military OneSource if they
                        need assistance during their transition. Similarly, a VA nurse who
                        responds to referrals from VA’s Veterans Crisis Line said that she
                        frequently receives referrals from the hotline from veterans who have



                        27
                          The requirements for a separation physical vary among the military services. In the
                        Army, retirees are required to have a separation physical, but servicemembers who are
                        separating at the end of their term of service are not required to have a physical.
                        Servicemembers in the Army also may waive the separation physical if they have
                        undergone a physical examination within 12 months of separation.
                        28
                          According to DOD officials, Military OneSource received approximately 1,500 calls daily
                        in May 2012. The national coordinator of VA’s Veterans Crisis Line said the hotline
                        receives more than 1,000 calls daily.




                        Page 16                                               GAO-13-26 DOD and VA Health Care
              problems with their medications, such as when they have let their
              medications lapse after discharging from the military and their symptoms
              have reemerged or they have experienced withdrawal symptoms. The
              national coordinator of VA’s Veterans Crisis Line told us hotline
              responders estimate that they receive about one call per day from a
              transitioning veteran with a medication issue.

Entry to VA   For servicemembers who transition to VA, there are departmental policies
              that can assist with medication needs upon entry into VA’s health care
              system, including VA’s nonformulary policy, DOD and VA’s data-sharing
              initiative, and VA’s policies for providing urgent care. Specifically, VA’s
              nonformulary policy—allowing providers to prescribe medications not on
              VA’s formulary if they establish clinical necessity—can help newly
              transitioned veterans avoid medication discontinuations due to
              differences in DOD’s and VA’s formularies. VA providers said they will
              typically continue existing medication therapies for patients who are new
              to VA, even if the medication is not on VA’s formulary, as long as the
              medication is effective and the veteran is stable on the medication. VA
              providers said their nonformulary requests are rarely denied and they
              have been able to keep new patients on nonformulary medications, or
              switch them to formulary medications when appropriate. A draft VA policy
              documents that VA providers are permitted to change previously
              prescribed DOD medications to medications on VA’s formulary for
              servicemembers who have separated from military service. 29 Some VA
              providers said they may change a new VA patient’s nonformulary
              medication to a VA formulary medication, but usually not when the patient
              is first entering VA, noting that it is important to establish relationships
              with patients before changing their medications. When comparing DOD’s
              and VA’s formularies for psychiatric and pain medications, we found that
              more than 50 percent of the psychiatric and pain medications on DOD’s
              formulary as of March 12, 2012, were also on VA’s formulary, and these
              medications represented the most utilized psychiatric and pain
              medications on DOD’s formulary in fiscal year 2011. Specifically, the
              medications on DOD’s formulary that were also on VA’s formulary
              represented 90 and 96 percent of the total number of prescriptions for



              29
                The draft policy also states that VA providers should continue DOD medication regimens
              for active duty servicemembers who are receiving care at VA. It clarifies that once a
              servicemember separates from the military, VA providers are permitted to change
              medications as appropriate. VA officials told us that they anticipate the policy will be
              released in December 2012.




              Page 17                                              GAO-13-26 DOD and VA Health Care
psychiatric and pain medications, respectively. (See app. II for our
comparison of DOD’s and VA’s formularies for psychiatric and pain
medications.)

Additionally, to help servicemembers transition to VA, DOD and VA have
a data-sharing initiative that allows DOD to electronically share historical
health information, including outpatient pharmacy data, on separated
servicemembers with VA on a monthly basis. Through this initiative,
known as the Federal Health Information Exchange, DOD transmits
certain information into a shared repository that VA can access and pull
into its own record system, available at all VA facilities. 30 The purpose of
the data-sharing initiative is to improve the safety and quality of care
provided at VA and to reduce costs by avoiding duplicative services.
Moreover, sharing of pharmacy data is important for medication
management during transitions because it improves continuity of care.
Although some VA providers access and use shared pharmacy data,
others told us they were not aware that they could access DOD data
through VA’s system, or could not always find DOD data, and as a result
had determined that looking for it typically was not worthwhile. DOD and
VA officials said that the data-sharing initiative is fully operational and
accessible at every VA facility. They said providers who do not use it may
not be familiar with how to access data or aware of what information is
available. They added that the information may not be as useful to
providers if veterans sought care from a private provider before coming to
VA because in those cases DOD’s data are not the veterans’ most recent
health information.

VA also has national policies in place to prioritize patients with urgent
health care needs and to provide such care on an expedited basis.
Following these policies, each VA medical center we visited had
procedures to accommodate “walk-in” patients—those who do not have
an appointment—who had not previously received care at VA and had an
urgent medical need. VA providers told us they ensure such patients are
seen the same day they walk in to the facility and, in the case of an
urgent medication need, are given enough medication to cover the period



30
  DOD and VA also share electronic health information through the Bidirectional Health
Information Exchange, which allows providers at both departments access to view
information on shared patients who receive care from both DOD and VA. This initiative
may help transition health care needs for Reservists and National Guard members who
may receive VA care prior to separating from the military.




Page 18                                               GAO-13-26 DOD and VA Health Care
                           until they can come in for a full assessment. Providers told us they
                           generally are able to provide any type of medication on a short-term
                           basis, including nonformulary medications and less commonly prescribed
                           medications, as long as patients are able to document their use of a
                           particular medication. VA providers told us that such walk-ins are
                           common and that walk-in procedures are in place so that any veteran
                           who is eligible for care will not be left with an unmet need. The National
                           Transitions of Care Coalition states that providing timely access to
                           healthcare providers is a critical component of safe and effective
                           transitions of care.


DOD and VA Provide         In addition to the efforts available to all servicemembers, DOD and VA
Additional Assistance to   have developed efforts for specific servicemember groups—such as
Meet Transitional          servicemembers with more complex health care needs or with mental
                           health conditions—that are designed to provide more thorough and direct
Medication Needs for       assistance with transitioning their health care, including components to
Specific Servicemember     help address medication needs. (See fig. 2.)
Groups




                           Page 19                                      GAO-13-26 DOD and VA Health Care
Figure 2: DOD and VA Efforts Targeted to Specific Servicemember Groups That
Provide Additional Assistance to Help Manage Medication Needs during Transitions
of Care




Page 20                                          GAO-13-26 DOD and VA Health Care
Prior to Discharge   Prior to discharge, DOD and VA have several additional efforts available
                     to servicemembers with complex health care needs or mental health
                     conditions that provide assistance with transitioning their medication
                     needs—including case management services and access to staff whose
                     primary focus is helping servicemembers connect with VA health care
                     services.

                     For example, servicemembers with complex health care needs may
                     receive case management services through military case managers or
                     Army WTUs, to help coordinate their medical care as they transition out of
                     the military, including medication management. 31 Military case
                     management services are available to servicemembers who have
                     catastrophic or multiple medical needs, which could include managing
                     medications. Family issues, seeing multiple providers, and a history of
                     noncompliance are also indicators of a need for military case
                     management. Military case managers are required to help connect
                     separating servicemembers with new health care providers and to assist
                     them with transitioning their health care needs, including medications. For
                     example, military case managers are required to fill out the VA referral
                     form and submit it, along with a discharge plan and medical record, to the
                     VA representative at the military treatment facility or the receiving VA
                     medical center. 32

                     Additionally, transitioning servicemembers in the Army with complex
                     health care needs may receive assistance through Army WTUs. The
                     Army WTU program is available to wounded Army servicemembers
                     whose injuries preclude them from contributing to their unit’s mission or
                     whose injuries are severe enough to require case management in order
                     to properly rehabilitate. According to Army officials, WTUs served nearly
                     19,000 servicemembers during fiscal year 2011. WTUs are designed to
                     help servicemembers remain in the Army or transition to civilian life,
                     guided by a Comprehensive Transition Plan to facilitate their process of
                     recovery and transition. Servicemembers are also assisted by a “Triad of


                     31
                        Military case managers and WTUs provide similar services for servicemembers with
                     complex health care needs, and DOD officials told us that unit commanders and military
                     clinicians use judgment in determining which is most appropriate for a servicemember.
                     Military case managers are also available to retirees and dependents, while WTUs are
                     limited to active duty servicemembers, Reservists, and National Guard members.
                     32
                      See Department of Defense, TRICARE Management Activity, Medical Management
                     Guide (Washington, D.C.: 2009).




                     Page 21                                               GAO-13-26 DOD and VA Health Care
Care” team—composed of a nurse case manager, primary care manager,
and squad leader. WTU policy requires nurse case managers to ensure a
“warm handoff” to the VA either by connecting the servicemember with a
VA representative stationed at the military treatment facility, or by
assisting the servicemember with the VA enrollment process and
contacting the receiving VA to coordinate follow-up care. 33 For example,
the primary care and nurse case managers at facilities we visited without
a VA representative on site told us they complete a VA referral form to
identify any needs for specialty care, such as mental health care. As
members of the Triad of Care team with the authority to prescribe
medications, primary care managers—who are typically physicians—also
can help WTU servicemembers prepare to manage their medications
during a transition. For instance, a primary care manager we spoke with
said that she ensures servicemembers have adequate supplies of
medications to cover their transition periods and counsels
servicemembers about the importance of adhering to their medication
regimens. 34

Some military case managers, WTU nurse case managers, and WTU
primary care managers we spoke with told us they take additional
measures when helping a servicemember transition to VA, including
giving the servicemember a hard copy of his or her medical record,
providing a list of his or her current medications, and writing a discharge
summary that describes the servicemember’s medical history and current
status. In addition, some military case managers and WTU nurse case
managers said servicemembers who have separated from the military
sometimes contact them with questions about their health care—including
medications. For example, servicemembers call them with questions
about how to schedule appointments at their local VA facility because
they need medications even though these individuals are no longer
formally receiving military case management services. Sharing copies of
medical records, providing a medication list, completing a discharge
summary, and having a clearly identified practitioner to facilitate and




33
 See Department of Defense, Department of the Army, Comprehensive Transition Plan:
Policy and CTP-Guidance (CTP-G) (Washington, D.C.: 2011).
34
  Squad leaders also help servicemembers prepare to transition out of the Army by
providing nonclinical assistance, such as ensuring that servicemembers attend required
briefings and vocational trainings prior to their separation from the military.




Page 22                                               GAO-13-26 DOD and VA Health Care
coordinate a patient’s care are all best practices for transitions between
health care providers. 35

In addition to DOD military case management and Army WTUs, VA also
provides assistance to servicemembers with complex health care needs
prior to discharge through VA’s Liaisons for Healthcare program. The
liaisons are VA employees stationed at military treatment facilities who
help ensure a smooth transition for servicemembers from those facilities
to VA. 36 For instance, at the military treatment facility we visited with VA
liaisons, the liaisons we spoke with said they would alert receiving VA
medical centers about potential increased risks of medication
discontinuation for patients for whom they had concerns. VA liaisons work
with military case managers and WTU nurse case managers at military
treatment facilities. Specifically, military case managers and WTU nurse
case managers at military treatment facilities with VA liaisons are able to
work directly with these liaisons to schedule appointments and share
medical information, eliminating the need to contact the receiving VA
medical centers. VA liaisons told us that although servicemembers are
typically referred to them by military or WTU case managers, they also
can assist servicemembers at their military treatment facility who do not
receive military or WTU case management services. According to VA, VA
liaisons assisted with approximately 6,500 referrals to VA and provided
28,500 educational consultations to servicemembers, families, and
military providers in fiscal year 2011. Providers told us that
servicemembers who receive assistance from a military case manager,
WTU nurse case manager, or VA liaison are more likely than
servicemembers who transition without this assistance to have a smooth
transition from DOD to VA, including the transition of their medications.




35
  See National Transitions of Care Coalition, Care Transition Bundle: Seven Essential
Intervention Categories (Washington, D.C.: Feb. 28, 2011); A. M. Spehar et al., “Seamless
Care: Safe Patient Transitions from Hospital to Home,” Advances in Patient Safety: From
Research to Implementation (Rockville, Md.: 2005); and T. Bodenheimer, “Coordinating
Care: A Perilous Journey through the Health Care System,” New England Journal of
Medicine, vol. 358, no. 10 (2008):1064-1071.
36
  According to VA officials, VA’s formula for determining which military treatment facilities
receive liaisons includes the total number of VA referrals made by each facility and patient
acuity, among other factors. As of September 2012, there were 33 VA liaisons stationed at
18 military treatment facilities. VA officials said that the program has been approved to
expand to 43 liaisons at 21 military treatment facilities in fiscal year 2013.




Page 23                                                 GAO-13-26 DOD and VA Health Care
                        Additionally, in March 2012, DOD released a policy to ensure continuity of
                        care for servicemembers receiving mental health care that outlines how to
                        appropriately transition care between providers, including addressing
                        psychiatric medication needs. 37 For instance, the policy directs the DOD
                        provider to contact, as appropriate, the receiving provider to communicate
                        the patient’s history, current status, needs during the transition period—
                        which could include medications—and to establish a follow-up
                        appointment to better ensure continuity of care. It also states that the
                        DOD provider should add a final summary of treatment in the patient’s
                        medical record. As with other DOD policies, this policy directs the
                        individual military services to develop their own detailed policies in line
                        with the general guidance for transitioning servicemembers’ mental health
                        care.

                        These efforts—military case management, WTUs, VA Liaisons for
                        Healthcare, and DOD’s mental health continuity of care policy—all include
                        elements that experts have identified as best practices for transitions of
                        care, such as sharing medical information directly between providers and
                        scheduling appointments with a receiving provider prior to discharge. 38

During the Transition   During the transition, servicemembers receiving mental health services
                        are eligible for additional assistance through the inTransition program—a
                        DOD program, with support from VA, established in 2010 to offer
                        specialized coaching and assistance to servicemembers receiving mental
                        health care as they transition between health care providers. The
                        program is available to servicemembers who are transitioning within DOD
                        and those who are separating from the military. Servicemembers can be
                        identified for inTransition services either by self-referral or physician-
                        referral. Coaches for inTransition are directed to contact servicemembers
                        at least once a week and are trained in motivational interviewing to
                        encourage servicemembers to continue their mental health care
                        treatment, which could include medications. Although many of the DOD
                        and VA providers we spoke with were unfamiliar with the inTransition
                        program, one DOD mental health care provider said she believes the
                        inTransition program is a useful resource and she shares the inTransition
                        information with her patients prior to their discharge. Similarly, a National


                        37
                          DOD refers to mental health care as behavioral health care. For consistency throughout
                        this report and other GAO reports, we use the term mental health care.
                        38
                         See National Transitions of Care Coalition, Care Transition Bundle.




                        Page 24                                               GAO-13-26 DOD and VA Health Care
              Guard member we interviewed during one of our site visits told us he was
              not familiar with the program but said it would be helpful if someone
              checked in on him after he demobilized and left active duty, as he
              sometimes forgets to take his medications because of the memory loss
              he experiences from an injury. According to the director of the
              inTransition program, the program provided coaching services to
              approximately 1,800 servicemembers and veterans from February 1,
              2010, through March 31, 2012. Coaching and education about how to
              self-manage one’s care during a transition are also consistent with best
              practices. 39

Entry to VA   Upon entry to VA, the OEF/OIF/OND Care Management Program can
              assist veterans with complex health care needs. Located at every VA
              medical center, the goal of the program is to coordinate patient care
              activities and ensure that OEF/OIF/OND veterans are receiving
              necessary care. Specifically, care management teams, which include
              program managers and case managers, work together to coordinate the
              care for veterans who need case management services and to receive
              patients when they arrive at VA. OEF/OIF/OND case managers also are
              required to contact veterans who have been referred by WTUs or military
              case managers prior to their first VA appointment. One veteran we
              interviewed during our site visits said he spoke with an OEF/OIF/OND
              case manager after his discharge, but prior to his first VA appointment.
              He described how he had run out of his medications—and had been
              cutting his psychiatric medication so it would last longer—and the case
              manager told him to come to a VA facility that day to see a provider and
              get his medications. Some case managers told us they also alert
              providers about any special needs, such as nonformulary medications,
              prior to a veteran’s first appointment. Prior to discharge, OEF/OIF/OND
              program managers also serve as VA contacts for all WTU nurse case
              managers, military case managers, and VA liaisons working with
              transitioning servicemembers. Although military case managers, WTU
              nurse case managers, and VA liaisons are the primary way veterans get
              connected to the OEF/OIF/OND Care Management Program, the
              program is also available to any OEF/OIF/OND veteran who arrives at a
              VA facility. Program managers are responsible for ensuring that every
              veteran of these conflicts is screened for case management services, and



              39
                See National Transitions of Care Coalition, Care Transition Bundle; T. Bodenheimer,
              “Coordinating Care”; and E. A. Coleman et al., “The Care Transitions Intervention.”




              Page 25                                               GAO-13-26 DOD and VA Health Care
                              veterans can request the services regardless of their screening results.
                              According to VA officials, the OEF/OIF/OND Care Management Program
                              was providing services to approximately 50,000 servicemembers and
                              veterans at the end of fiscal year 2011.


Local DOD and VA Facility     Some DOD military treatment facilities and VA medical centers have
Efforts Can Help Meet         developed local policies and procedures that can help servicemembers
Servicemembers’               transition their care and manage their medications. For example, some
                              military treatment facilities provide medication lists to servicemembers
Transitional Medication       prior to discharge, and some VA medical centers conduct outreach to
Needs but May Not Be          military treatment facilities. However, these efforts are not part of formal
Available at All Facilities   department-wide policies and are implemented at the discretion of
                              individual facilities.

                              Two of the three military treatment facilities we visited had local policies
                              that require providers to give patients a current medication list at the end
                              of each appointment, including their last medical appointment prior to
                              discharge. For instance, the list at one facility includes the medication
                              name, dosage, directions for use, date of last fill, number of refills, and
                              prescribing physician. Medication lists can assist servicemembers with
                              medication management during transitions of care, including by helping to
                              remind them to take their medications and to adhere to prescribed
                              treatment regimens. Medication lists also can improve continuity of care
                              during transitions by providing documentation of a patient’s current
                              medications. At the military treatment facility we visited that does not have
                              this type of policy, case managers and providers told us they sometimes
                              provide this type of information to servicemembers even though it is not
                              required at their facility. The National Transitions of Care Coalition has
                              identified medication lists as a best practice during transitions to ensure
                              safe use of medications and adherence to patients’ plans of care.
                              Additionally, The Joint Commission, an accrediting body for health care
                              organizations, includes medication lists in one of its patient safety goals.

                              In another example of local efforts to help meet transitional medication
                              needs, officials from two VA medical centers we visited said they send
                              staff to military treatment facilities or military bases without VA Liaisons
                              for Healthcare to educate servicemembers about VA health care.
                              According to officials at these VA medical centers, having a point of
                              contact at VA increases the likelihood that servicemembers will call VA for
                              care and may make them less likely to experience a discontinuation in
                              their medication use. For instance, officials at one medical center we
                              visited said they send OEF/OIF/OND care management staff to National


                              Page 26                                         GAO-13-26 DOD and VA Health Care
              Guard demobilization events to help National Guard members returning
              from combat begin the process of enrolling in VA health care. Officials at
              another medical center said they send OEF/OIF/OND care management
              staff to a nearby Army military treatment facility that does not have a VA
              Liaison for Healthcare so they can act as informal VA liaisons, educating
              servicemembers about VA health care and providing VA enrollment
              forms. These activities also provide servicemembers with a VA point of
              contact during their transitions. Officials at these medical centers said
              these efforts improve the transition of care between DOD and VA and can
              reduce the likelihood of a veteran discontinuing medication use.
              Additionally, two veterans we spoke with described the benefit of having
              VA staff reach out to them while they were still on active duty.
              Specifically, one veteran told us an OEF/OIF/OND case manager called
              him prior to discharging from the Army to help him schedule his first
              appointment at VA and that this connection helped ensure he had a
              smooth transition of his health care, including his medications. While
              OEF/OIF/OND Care Management program materials suggest that
              OEF/OIF/OND Care Management staff are encouraged to conduct
              outreach to active duty servicemembers, this type of outreach is not
              required by VA policy. Instead, this type of outreach is directed by local
              VA medical centers.


              Continuity of health care, especially with respect to medication
Conclusions   management, is important for servicemembers who are transitioning out
              of the military and changing health care providers. Ensuring psychiatric
              and pain medications are continued during transitions is particularly
              important given the potential adverse health effects that can be
              experienced in response to misusing or abruptly discontinuing them.
              Given that DOD may be the last provider of health care prior to discharge,
              the department has primary responsibility for preparing servicemembers
              for transitions of care. DOD’s medical assessment is a key opportunity for
              assisting all servicemembers with managing medications, but there is no
              assurance that best practices, such as providing current medication lists
              at the point of discharge, are included in these assessments. Additionally,
              although DOD and VA have several other efforts that implement one or
              more best practices for managing medications during transitions, these
              efforts are available only to specific groups or to servicemembers
              accessing certain DOD or VA facilities. DOD does not have a department-
              wide policy to help ensure that all transitioning servicemembers’
              medication needs are managed. Without such a policy, DOD cannot
              ensure, for example, that the basic step of providing current medication
              lists at the point of discharge is implemented across all its military


              Page 27                                      GAO-13-26 DOD and VA Health Care
                      facilities, including for the approximately 50 percent of servicemembers
                      discharged with psychiatric or pain medications who do not connect with
                      VA providers in a timely manner, if at all. As such, the departments
                      cannot be assured that servicemembers’ medication needs are
                      sufficiently met during transitions. Furthermore, best practices
                      implemented locally or in specialized programs—such as scheduling VA
                      appointments prior to discharge for WTU servicemembers—could benefit
                      a broader population of servicemembers. Identifying best practices and
                      implementing them across the departments could better ensure overall
                      continuity of care, including medication management, for servicemembers
                      transitioning between health care providers.


                      To help ensure appropriate medication management for all
Recommendations for   servicemembers during transitions, we recommend that the Secretary of
Executive Action      Defense direct the Under Secretary of Defense for Personnel and
                      Readiness to develop a formal DOD transition policy for medications that
                      applies to all servicemembers, including a requirement that all
                      servicemembers be provided a current medication list prior to
                      transitioning out of the military and changing health care providers.

                      We also recommend that the Secretary of Defense direct the Under
                      Secretary of Defense for Personnel and Readiness, and the Secretary of
                      Veterans Affairs direct the Under Secretary for Health, to work together to
                      identify and apply best practices for managing servicemembers’
                      medication needs during transitions of care, including assessing the
                      extent to which practices currently available within existing transition
                      policies and programs that are targeted to specific servicemember and
                      veteran groups can be made more widely available.


                      We provided a draft of this report to DOD and VA for comment. Both
Agency Comments       departments concurred with our recommendations, and the departments’
and Our Evaluation    responses are reprinted in appendixes III and IV. In its response, DOD
                      provided comments on the medication list component of our
                      recommendation for it to develop a transition policy for medications that
                      applies to all servicemembers. DOD stated that servicemembers may
                      receive a copy of their medical records, which would include a list of
                      current medications. However, DOD does not provide all servicemembers
                      a copy of their medical records. DOD also indicated that medication




                      Page 28                                       GAO-13-26 DOD and VA Health Care
information for servicemembers is already shared with VA through the
Bidirectional Health Information Exchange. However, as we noted in our
report, this data-sharing initiative is limited to shared patients—such as
servicemembers who receive care from both DOD and VA prior to
separating from the military. Moreover, not all servicemembers
discharged from DOD subsequently receive care from VA. We believe
that it is important that all servicemembers transitioning out of the DOD
health care system be provided with a medication list at discharge, which
is important for helping to ensure medications are used appropriately and
that there is continuity of care for servicemembers changing health care
providers.

In response to our recommendation that DOD and VA work together to
identify and apply best practices for managing servicemembers’
medication needs during transitions of care, DOD specified that it would
work with VA to identify best practices such as reducing medication
errors. As DOD identifies and applies best practices, it should focus on
practices that will help manage servicemembers’ medication needs during
transitions of care. As we have identified in our report, some of these best
practices are currently available within existing transition policies and
programs and could be made more widely available. Additionally, VA
stated that its Veterans Health Administration has several efforts under
way to address the challenges associated with the medication needs of
transitioning servicemembers. VA also provided technical comments,
which we have incorporated as appropriate.


As agreed with your office, unless you publicly announce the contents of
this report earlier, we plan no further distribution until 12 days from the
report date. At that time, we will send copies of this report to the
Secretary of Defense, Secretary of Veterans Affairs, and appropriate
congressional committees. In addition, the report will be available at no
charge on the GAO website at http://www.gao.gov.




Page 29                                       GAO-13-26 DOD and VA Health Care
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made key contributions to this report
are listed in appendix V.

Sincerely yours,




Debra A. Draper
Director, Health Care




Page 30                                     GAO-13-26 DOD and VA Health Care
Appendix I: Scope and Methodology
             Appendix I: Scope and Methodology




             To determine the extent to which servicemembers transitioned out of the
             Department of Defense (DOD) health care system with psychiatric or pain
             medications, we obtained data from DOD’s Defense Manpower Data
             Center and Defense Health Cost Assessment and Program Evaluation on
             the number of servicemembers who discharged and Reservists and
             National Guard members who demobilized with psychiatric or pain
             medications in fiscal years 2009, 2010, and 2011. The Defense
             Manpower Data Center provided us with a list of active duty
             servicemembers, Reservists, and National Guard members who
             discharged or were released (including retirees) from military service
             generally under conditions other than dishonorable and a list of
             Reservists and National Guard members who demobilized. We included
             servicemembers who discharged and Reservists and National Guard
             members who demobilized because servicemembers in both of these
             populations can transition out of the DOD health care system and could
             be eligible for VA care. For servicemembers who had multiple discharge
             or demobilization dates within a fiscal year, we used the latest date.
             DOD’s Pharmacoeconomic Center provided us with a list of psychiatric
             and pain medications. 1 DOD’s Defense Health Cost Assessment and
             Program Evaluation then reviewed TRICARE claims files for discharged
             and demobilized servicemembers to determine if they had a current
             psychiatric or pain medication when they discharged or demobilized. Data
             from the claims files identifies prescriptions that were filled, not all
             prescriptions that were written. Furthermore, because some psychiatric
             and pain medications may be prescribed for conditions other than mental
             health or pain conditions, the number of servicemembers with psychiatric
             or pain medications is not equivalent to the number of servicemembers
             with related conditions.

             To determine how many of those servicemembers discharged from
             military service and Reservists and National Guard members demobilized
             with psychiatric or pain medications subsequently received care at the
             Department of Veterans Affairs (VA), we obtained data from VA’s
             National Data System on how many of these servicemembers
             subsequently received health care from VA. We provided VA with the list
             of servicemembers who discharged from military service or demobilized


             1
              DOD’s Pharmacoeconomic Center excluded psychiatric and pain medications that were
             available over-the-counter, were bulk medications used by pharmacists for compounding,
             and were provided through certain routes of administration, such as intravenous pain
             medications.




             Page 31                                              GAO-13-26 DOD and VA Health Care
Appendix I: Scope and Methodology




with a psychiatric or pain medication in fiscal years 2009, 2010, or 2011.
VA compared the data to its electronic medical records to identify which
servicemembers received care at VA within 9 months of their discharge or
demobilization date. We selected the 9-month time frame to provide
consistent data across each of the 3 fiscal years—the most current
available VA data at the time of our review were from June 2012,
9 months after the end of fiscal year 2011. Data on servicemembers who
subsequently received care from VA do not describe the full population of
servicemembers who received care after being discharged from military
service or demobilized. Not all servicemembers subsequently seek and
receive care from VA; some receive care from other sources, such as
private providers.

We assessed the reliability of the data in several ways, including
discussing with DOD and VA officials their methodology and data-
collection techniques and conducting our own review of their
programming and methodological approaches using data file
documentation, code book and file dictionaries, and programming logs.

To identify the efforts DOD and VA have in place to help ensure that
servicemembers’ psychiatric and pain medication needs are met during
transitions of care, we reviewed documents and interviewed officials from
DOD, the Department of the Army, and VA. We focused our review on the
Army, rather than the other military services, because it had the largest
number of Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF) 2 servicemembers. We reviewed documents including
DOD, Army, and VA policies related to health care and medication
transitions. For example, we reviewed the Army Surgeon General Pain
Management Task Force Report, VA’s National Pain Management
Strategy, and VA/DOD Clinical Practice Guideline for Management of
Opioid Therapy for Chronic Pain. 3 We interviewed officials from DOD,
Army, and VA headquarters offices that have oversight of, and set



2
 Military operations in Iraq as of September 1, 2010, are referred to as Operation New
Dawn (OND).
3
 See Office of the Army Surgeon General, Pain Management Task Force, Providing a
Standardized DOD and VHA Vision and Approach to Pain Management to Optimize the
Care for Warriors and their Families (May 2010); Department of Veterans Affairs, Pain
Management, VHA Directive 2009-053 (Washington, D.C.: Oct. 28, 2009); and
Department of Veterans Affairs and Department of Defense, VA/DOD Clinical Practice
Guideline for Management of Opioid Therapy for Chronic Pain (May 2010).




Page 32                                                GAO-13-26 DOD and VA Health Care
Appendix I: Scope and Methodology




policies related to, the provision of health care, including mental health
and pain care and prescription-medication benefits, and that have roles in
assisting servicemembers with their health care as they transition out of
DOD. Specifically, we interviewed officials from

•   DOD’s TRICARE Management Activity’s Clinical Quality Office,
    Pharmacoeconomic Center, and Case Management Program;
    Reserve Medical Programs; Defense Health Information Management
    System; and inTransition Program;

•   Office of the Surgeon General of the Army; Army National Guard; and
    Army Pain Management Program; and

•   VA’s VA/DOD Collaboration Office and Veterans Health
    Administration’s Pharmacy Benefits Management Services, Veterans
    Crisis Line, inTransition Program, Office of Health Information, Pain
    Management Program, Liaisons for Healthcare Program, and
    OEF/OIF/OND Care Management Program.

We also interviewed officials, including providers and case managers,
from Army military treatment facilities and VA medical centers, as well as
servicemembers and veterans, through six site visits to obtain their
perspectives about how the departments’ efforts to transition
servicemembers with medication needs are being implemented and to
identify local efforts to assist servicemembers with medication
management during transitions. We selected sites to obtain a diverse
sample based on facility size, patient complexity, presence or absence of
a VA Liaison for Healthcare, and Army and VA region, and to ensure
military treatment facility proximity to a VA medical center. On the basis of
these criteria we selected the following facilities: (1) Walter Reed National
Military Medical Center (Bethesda, Md.); (2) Washington D.C. VA Medical
Center; (3) Bayne-Jones Army Community Hospital (Fort Polk, La.);
(4) Alexandria VA Medical Center (Pineville, La.); (5) Weed Army
Community Hospital (Fort Irwin, Calif.); and (6) Loma Linda (Calif.) VA
Medical Center. Finally, we also interviewed officials from selected
veterans service organizations—the American Legion, Military Officers
Association of America, and Wounded Warrior Project—to get their
perspectives on transition policies and programs and where there are
opportunities to improve the handoff from DOD to VA.




Page 33                                        GAO-13-26 DOD and VA Health Care
Appendix I: Scope and Methodology




We focused our review on efforts that department officials and local
military treatment facility and VA medical center officials identified as
having a role in helping servicemembers manage their medications as
they transition from DOD to VA. We also focused on the transition efforts
used for servicemembers transitioning between outpatient settings, rather
than inpatient settings, because medication management between
outpatient settings is a vulnerable point in terms of providing seamless
care. We may not report an exhaustive list of all efforts because some
servicemembers may have received help through efforts that were not
identified by the officials we interviewed or through efforts that may not
have been related to the health care aspects of their transition. We did
not review the effectiveness of the efforts identified.

Additionally, we reviewed relevant literature on transitions of care and
medication adherence, including effective approaches for transitioning
health care needs and strategies for promoting patient adherence to
medication treatment plans. For example, we reviewed literature from the
National Transitions of Care Coalition, a nonprofit organization that works
to address gaps that affect safety and quality of care for transitioning
patients, to identify best practices within DOD’s and VA’s transition
efforts.

We conducted this performance audit from January 2012 to October 2012
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.




Page 34                                       GAO-13-26 DOD and VA Health Care
Appendix II: Formulary Comparison
             Appendix II: Formulary Comparison




             In comparing DOD’s and VA’s formularies for psychiatric and pain
             medications, we determined which psychiatric and pain medications on
             DOD’s formulary were also on VA’s formulary. 1 DOD’s
             Pharmacoeconomic Center provided us with a list of the psychiatric and
             pain medications on DOD’s formulary, as of March 12, 2012. 2 We
             compared this list with VA’s full formulary, found on VA’s Veterans Health
             Administration’s Pharmacy Benefits Management Services website, as
             recommended by VA pharmacy officials. 3 We compared medications
             using generic names; we did not compare medications based on
             differences in strength or dosage form, such as whether the medication is
             a liquid or a tablet. 4 DOD also provided data on the number of
             prescriptions filled for psychiatric and pain medications by active duty
             servicemembers to provide additional context for our comparison. We
             spoke with knowledgeable DOD pharmacy officials about the data,
             including their methodology for identifying psychiatric and pain
             medications, and with DOD and VA officials about our methodology for
             comparing the formularies. On the basis of these discussions, we
             determined the data to be sufficiently reliable for our purposes.

             We found that 57 percent of the psychiatric and pain medications on
             DOD’s formulary were also on VA’s formulary, and these medications
             represented the most utilized psychiatric and pain medications on DOD’s
             formulary. (See table 4.) Specifically, the medications on DOD’s formulary
             that were also on VA’s formulary—62 psychiatric medications and 31 pain
             medications—represented 90 and 96 percent of the total number of



             1
              Because we focused on transitions of care from DOD to VA, we did not determine which
             medications on VA’s formulary were not on DOD’s formulary.
             2
              DOD’s Pharmacoeconomic Center excluded psychiatric and pain medications that were
             available over-the-counter, were bulk medications used by pharmacists for compounding,
             and were provided through certain routes of administration, such as intravenous pain
             medications.
             3
              VA, “VA National Formulary,” accessed March 16, 2012,
             http://www.pbm.va.gov/NationalFormulary.aspx. VA officials confirmed that there had
             been no changes to the formulary between March 12, 2012, and March 16, 2012.
             4
              According to DOD and VA pharmacists, differences in dosage form do not typically
             correspond to clinically significant differences. However, in some cases, different dosage
             forms may be prescribed for different clinical indications and may have significant
             implications for patients. For instance, some opioids are prescribed in an immediate-
             release formulation for breakthrough pain, whereas a long-acting formulation may be
             prescribed for chronic pain.




             Page 35                                                 GAO-13-26 DOD and VA Health Care
Appendix II: Formulary Comparison




prescriptions for psychiatric and pain medications, respectively, filled by
active duty servicemembers in fiscal year 2011.

DOD and VA pharmacy officials said that some of the differences in
DOD’s and VA’s formularies are due to differences in the structure of the
departments’ health care systems. For example, DOD’s formulary covers
prescriptions written by both military and civilian providers and, as a
result, DOD officials said that the department needs to have a broader
formulary to account for differences in prescribing practices among
different providers. In contrast, VA has a closed system and provides
prescriptions written by its own providers, which VA officials said allows
VA to have more direct control over the medications that are prescribed to
its patient population. VA officials also emphasized that VA regularly
provides nonformulary medications to veterans through its nonformulary
request process that allows providers to prescribe medications not on
VA’s formulary if they can establish clinical necessity. 5 VA providers at
the three sites we visited told us that they find the nonformulary request
process easy to use and that their nonformulary requests are rarely
denied.




5
 Each VA medical center is responsible for establishing a process to adjudicate
nonformulary medication requests that ensures decisions are evidence-based in
accordance with certain prescribing criteria. Medical centers are required to adjudicate
nonformularly medication requests within 96 hours.




Page 36                                                 GAO-13-26 DOD and VA Health Care
Appendix II: Formulary Comparison




Table 4: Comparison of DOD’s and VA’s Formularies for Psychiatric and Pain
Medications, March 2012

                                                             Percentage of DOD
                                                             prescriptions filled
                                                                  by active duty
                                        Medication on VA’s    servicemembers,
                                    a
Medication on DOD’s formulary               formulary           fiscal year 2011
Psychiatric
     Sertraline Hydrochloride                                               10.7%
     Citalopram Hydrobromide                                                  8.8
     Bupropion Hydrochloride                                                  7.5
     Diazepam                                                                 7.0
     Trazodone Hydrochloride                                                  6.9
     Clonazepam                                                               5.5
     Venlafaxine Hydrochloride                                                5.3
     Fluoxetine Hydrochloride                                                 5.2
     Amphet Asp Amphet D Amphet                                                4.6
     Quetiapine Fumarate                                                      4.4
     Amitriptyline Hydrochloride                                              3.5
     Topiramate                                                               3.5
     Alprazolam                                                               2.8
     Lorazepam                                                                2.5
     Methylphenidate Hydrochloride                                            2.2
     Paroxetine Hydrochloride                                                 2.2
     Mirtazapine                                                              1.8
     Duloxetine Hydrochloride                                                  1.7
     Aripiprazole                                                             1.5
     Buspirone Hydrochloride                                                  1.4
     Divalproex Sodium                                                        1.4
     Nortriptyline Hydrochloride                                              1.2
     Lamotrigine                                                              1.1
     Risperidone                                                              0.8
     Modafinil                                                                 0.7
     Olanzapine                                                               0.5
     Levetiracetam                                                            0.5
     Atomoxetine Hydrochloride                                                 0.5
     Lithium Carbonate                                                        0.4
     Oxcarbazepine                                                             0.4
     Armodafinil                                                               0.3




Page 37                                          GAO-13-26 DOD and VA Health Care
Appendix II: Formulary Comparison




                                                                Percentage of DOD
                                                                prescriptions filled
                                                                     by active duty
                                           Medication on VA’s    servicemembers,
                                    a
Medication on DOD’s formulary                  formulary           fiscal year 2011
     Dextroamphetamine Sulfate                                                 0.3
     Doxepin Hcl                                                               0.3
     Ziprasidone Hydrochloride                                                 0.3
     Carbamazepine                                                             0.2
     Desvenlafaxine Succinate                                                   0.2
     Lisdexamfetamine Dimesylate                                                0.1
     Zonisamide                                                                 0.1
                                                                                      b
     Phenytoin Sodium Extended                                                 0.1
     Imipramine Hydrochloride                                                  0.1
     Milnacipran Hydrochloride                                                  0.1
     Fluvoxamine Maleate                                                        0.1
     Primidone                                                               < 0.1
     Desipramine Hydrochloride                                               < 0.1
     Sodium Oxybate                                                           < 0.1
     Asenapine Maleate                                                        < 0.1
     Haloperidol                                                             < 0.1
     Chlorpromazine Hydrochloride                                            < 0.1
     Chlordiazepoxide Hydrochloride                                          < 0.1
     Lacosamide                                                               < 0.1
     Clomipramine Hydrochloride                                              < 0.1
     Phenelzine Sulfate                                                      < 0.1
     Clorazepate Dipotassium                                                  < 0.1
     Nefazodone Hydrochloride                                                 < 0.1
     Paliperidone                                                            < 0.1
     Dexmethylphenidate Hydrochloride                                         < 0.1
     Guanfacine Hydrochloride                                                 < 0.1
     Oxazepam                                                                 < 0.1
     Olanzapine Fluoxetine Hydrochloride          c                          < 0.1
     Clozapine                                                               < 0.1
     Perphenazine                                                            < 0.1
     Phenobarbital                                                           < 0.1
     Valproic Acid                                                           < 0.1
     Imipramine Pamoate                                                      < 0.1




Page 38                                            GAO-13-26 DOD and VA Health Care
Appendix II: Formulary Comparison




                                                             Percentage of DOD
                                                             prescriptions filled
                                                                  by active duty
                                        Medication on VA’s    servicemembers,
                                    a
Medication on DOD’s formulary               formulary           fiscal year 2011
     Phenytoin                                                            < 0.1
     Protriptyline Hydrochloride                                           < 0.1
     Vilazodone Hydrochloride                                              < 0.1
     Amitriptyline Hydrochloride
     Chlordiazepoxide                          c                          < 0.1
     Paroxetine Mesylate                                                  < 0.1
     Loxapine Succinate                                                   < 0.1
     Lurasidone Hydrochloride                                              < 0.1
     Perphenazine Amitriptyline                c                          < 0.1
     Pimozide                                                             < 0.1
     Bupropion Hydrobromide                                               < 0.1
     Thiothixene                                                          < 0.1
     Selegiline                                                           < 0.1
     Fluphenazine Hydrochloride                                           < 0.1
     Valproate Sodium                                                      < 0.1
     Maprotiline Hydrochloride                                             < 0.1
     Methamphetamine Hydrochloride                                         < 0.1
     Isocarboxazid                                                         < 0.1
     Ethosuximide                                                          < 0.1
     Lithium Citrate                                                      < 0.1
     Tranylcypromine Sulfate                                              < 0.1
     Thioridazine Hydrochloride                                            < 0.1
     Trifluoperazine Hydrochloride                                        < 0.1
     Clonidine Hydrochloride                                              < 0.1
     Amoxapine                                                             < 0.1
     Haloperidol Lactate                                                  < 0.1
     Clobazam                                                                0.0
     Ethotoin                                                                0.0
     Felbamate                                                              0.0
     Mephobarbital                                                           0.0
     Meprobamate                                                             0.0
     Methsuximide                                                            0.0
     Molindone Hydrochloride                                                0.0
     Rufinamide                                                              0.0




Page 39                                         GAO-13-26 DOD and VA Health Care
Appendix II: Formulary Comparison




                                                             Percentage of DOD
                                                             prescriptions filled
                                                                  by active duty
                                        Medication on VA’s    servicemembers,
                                    a
Medication on DOD’s formulary               formulary           fiscal year 2011
     Trimipramine Maleate                                                    0.0
     Vigabatrin                                                              0.0
                                                                                d
Subtotal psychiatric 99                      62 (63%)                     100%
Pain
     Ibuprofen                                                             27.8
     Hydrocodone Bit Acetaminophen                                         14.0
     Oxycodone Hydrochloride
     Acetaminophen                                                         13.8
     Naproxen                                                              11.4
     Tramadol Hydrochloride                                                 6.5
     Cyclobenzaprine Hydrochloride                                          6.5
     Meloxicam                                                              5.0
     Celecoxib                                                               2.7
     Gabapentin                                                             2.3
     Acetaminophen With Codeine                                             2.0
     Oxycodone Hydrochloride                                                1.7
     Diclofenac Sodium                                                      1.0
     Indomethacin                                                           0.8
     Morphine Sulfate                                                       0.5
     Piroxicam                                                              0.4
     Naproxen Sodium                                                        0.3
     Hydromorphone Hydrochloride                                            0.3
     Ketorolac Tromethamine                                                 0.3
     Etodolac                                                               0.2
     Tramadol Hydrochloride
     Acetaminophen                                                           0.2
     Buprenorphine Hydrochloride
     Naloxone                                                               0.1
     Diclofenac Epolamine                                                    0.1
     Fentanyl                                                               0.1
     Oxymorphone Hydrochloride                                               0.1
     Hydrocodone Ibuprofen                                                   0.1
     Methadone Hcl                                                          0.1
     Nabumetone                                                              0.1
     Meperidine Hydrochloride                                               0.1




Page 40                                         GAO-13-26 DOD and VA Health Care
Appendix II: Formulary Comparison




                                                                Percentage of DOD
                                                                prescriptions filled
                                                                     by active duty
                                           Medication on VA’s    servicemembers,
                                    a
Medication on DOD’s formulary                  formulary           fiscal year 2011
     Oxaprozin                                                                  0.1
     Diclofenac Potassium                                                      0.1
     Sulindac                                                                < 0.1
     Diclofenac Sodium Misoprostol                                            < 0.1
     Diflunisal                                                               < 0.1
     Tapentadol Hydrochloride                                                 < 0.1
     Codeine Sulfate                                                         < 0.1
     Buprenorphine                                                           < 0.1
     Ketoprofen                                                               < 0.1
     Tolmetin Sodium                                                          < 0.1
     Salsalate                                                               < 0.1
     Dihydrocodeine Aspirin Caffeine                                          < 0.1
     Naproxen Esomeprazole Magnesium                                          < 0.1
     Buprenorphine Hydrochloride                                             < 0.1
     Mefenamic Acid                                                           < 0.1
     Butorphanol Tartrate                                                    < 0.1
     Codeine Butalbital Acetaminophen
     Caffeine                                                                 < 0.1
     Flurbiprofen                                                            < 0.1
     Morphine Sulfate/Naltrexone                                              < 0.1
     Pentazocine Hydrochloride Naloxone
     Hydrochloride                                                            < 0.1
     Fentanyl Citrate                                                        < 0.1
     Dihydrocodeine Bitartrate
     Acetaminophen Caffeine                                                   < 0.1
     Oxycodone Hydrochloride
     Oxycodone Terephthalate Aspirin                                          < 0.1
     Pentazocine Hydrochloride
     Acetaminophen                                                            < 0.1
     Fenoprofen Calcium                                                       < 0.1
     Ibuprofen Oxycodone Hydrochloride                                        < 0.1
     Meclofenamate Sodium                                                     < 0.1
     Oxycodone Hydrochloride Aspirin                                          < 0.1
     Codeine Butalbital Aspirin Caffeine                                      < 0.1
     Choline Sal Magnesium Salicylate                                         < 0.1
     Levorphanol Tartrate                                                     < 0.1




Page 41                                            GAO-13-26 DOD and VA Health Care
Appendix II: Formulary Comparison




                                                                                Percentage of DOD
                                                                                prescriptions filled
                                                                                     by active duty
                                                     Medication on VA’s          servicemembers,
                                           a
    Medication on DOD’s formulary                        formulary                 fiscal year 2011
         Meperidine Hydrochloride Prometh
         Hydrochloride                                                                          < 0.1
         Aspirin Codeine Phosphate                                                              < 0.1
         Carisoprodol Codeine Phosphate
         Aspirin                                                                                < 0.1
         Ibuprofen Famotidine                                                                    0.0
         Lansoprazole Naproxen                                                                   0.0
         Magnesium Salicylate                                                                    0.0
                                                                                                      d
    Subtotal pain 65                                       31 (48%)                            100%
    Total 164                                              93 (57%)
Source: GAO analysis of DOD and VA data.
a
 This analysis does not include psychiatric or pain medications on DOD’s formulary that were
available over-the-counter, were bulk medications used by pharmacists for compounding, and were
provided through certain routes of administration, such as intravenous pain medications.
b
    Prescriptions for phenytoin sodium extended includes prescriptions for phenytoin sodium.
c
 VA generally does not include combination medications on its formulary. However, VA officials told
us that their providers can prescribe several medications together, which can be equivalent to the
combination medication. Therefore, in cases where VA’s formulary includes the individual
medications that make up a particular combination medication, we have marked it as being on VA’s
formulary.
d
    Percentages do not sum to 100 due to rounding.




Page 42                                                         GAO-13-26 DOD and VA Health Care
Appendix III: Comments from the
              Appendix III: Comments from the Department
              of Defense



Department of Defense




              Page 43                                      GAO-13-26 DOD and VA Health Care
Appendix III: Comments from the Department
of Defense




Page 44                                      GAO-13-26 DOD and VA Health Care
Appendix IV: Comments from the
             Appendix IV: Comments from the Department
             of Veterans Affairs



Department of Veterans Affairs




             Page 45                                     GAO-13-26 DOD and VA Health Care
Appendix IV: Comments from the Department
of Veterans Affairs




Page 46                                     GAO-13-26 DOD and VA Health Care
Appendix IV: Comments from the Department
of Veterans Affairs




Page 47                                     GAO-13-26 DOD and VA Health Care
Appendix IV: Comments from the Department
of Veterans Affairs




Page 48                                     GAO-13-26 DOD and VA Health Care
Appendix V: GAO Contact and Staff
                  Appendix V: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Debra A. Draper, (202) 512-7114 or draperd@gao.gov
GAO Contact
                  In addition to the contact named above, Janina Austin, Assistant Director;
Staff             Jennie Apter; Lisa Motley; Leslie Powell; Dan Ries; and Karin Wallestad
Acknowledgments   made key contributions to this report.




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                  Page 49                                      GAO-13-26 DOD and VA Health Care
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