Little uniformity in military health care


U.S. Military veteran and amputee Lloyd Epps has reflective devices placed on his body by Jason Maikos, director of the gait and motion analysis lab at the Veterans Administration hospital in New York City. (John Moore/Getty Images)
Walter Pincus
Reporter February 24

A new series of critical reports highlights the need to speed up unification of the military services’ separate approaches to health care, which is one of the fastest-growing budget items but still lacks common standards for dealing with some medical issues.

The Military Health System, which provides care to more than 9.7 million active, retired and service-family beneficiaries worldwide, cost $51.4 billion in fiscal 2012, or 9.7 percent of Pentagon spending. That was up from $19 billion in fiscal 2001, or 6 percent of spending.

The Congressional Budget Office has projected health spending could reach $65 billion in fiscal 2017 and $92 billion by 2030.

Forget all that talk of jointness that grew out of the passage of the Goldwater-Nichols Act 28 years ago. There are still separate surgeons general for the Army, Navy and Air force — at the three-star rank — each responsible for overseeing his or her own medical forces and health-care systems.

It was nine years ago when the Government Accountability Office first suggested that the Pentagon could “achieve economies of scale and improve delivery [of medical care] by combining, realigning or otherwise changing selected support functions.” In 2011, the GAO in a report on reducing duplication in government programs focused on the Defense Department’s health-care system not having a “central command authority or single entity accountable for minimizing costs and achieving efficiencies.”

The Pentagon took a step in 2012 to change the system, which Congress codified in the fiscal 2013 Defense Authorization Act. Reform began with the Oct. 1, 2013, establishment of the Defense Health Agency (DHA), headed by the undersecretary of defense for personnel and readiness. The new structure was designed to better integrate common management functions such as information technology, medical research, facility planning, medical logistics, contracting and budget management.

It is underway, but with the military being the military, jointness doesn’t happen quickly. A Military Health Service Governance Transition Organization had to be created in March 2013 with its own transition bureaucracy — an “action group, an advisory council, along with a review board, each with specific roles and responsibilities,” according to the GAO. The organization is to oversee the process through October 2015, when the DHA is expected to be fully operational.

What savings are possible? Jointly implementing just the facility planning — operating current medical facilities (there are about 1,000) and constructing new ones — through shared services could potentially save $1.1 billion over six years, the Pentagon told Congress in June.

The most recent illustration of the lack of coordination came Friday, when the Defense Department’s inspector general reported that the military services have varied policies even when dealing with Wounded Warriors programs, which deal with service personnel injured since Sept. 11.

The IG report focuses on the services’ separate standards for monitoring medications for Wounded Warriors programs and particularly controlled substances, but it points out there are even service differences in what’s needed for admission into their programs.

The Army, for example, requires the soldier to have had a medical condition “that demanded at least six months of complex medical management,” while the Marine Corps standard was that the individual had “to have medical conditions that demanded treatment for more than 90 days.”

The Air Force requires an injury or illness that is combat- or hostilities-related, requiring an unspecified amount of long-term care and a medical evaluation board or physical evaluation board to determine fitness for duty. The Navy has a similar standard.

When it comes to drugs, the IG reported that the Army’s threshold for monitoring an individual was someone taking “four medications when one is a controlled substance,” while the Navy hospital at Marine Corps Base Camp Lejeune in North Carolina was “five controlled substances.” The Camp Lejeune policy also had a system for identifying “doctor shopping” — an individual going to multiple doctors with the same prescription to get more drugs — while the Army has none.

The IG noted that the differences are important when an Army wounded warrior requires special care at a Navy facility “where the same level of medication oversight” does not exist.

The thrust of the IG report is that the Defense Department has “not issued overarching policy guidance to address the risks involved in managing wounded warriors’ multiple medications,” but a consistent policy for that high-risk patient population will “decrease the risk of adverse drug events and poor patient outcomes.”

On Thursday, the Institute of Medicine in a report questioned the various Defense Department programs dealing with psychological problems of service members and their families.

While the Defense Department-sponsored study was based on reviewing earlier studies, its experts pointed out that many programs were “not consistently based on evidence . . . [and] are evaluated infrequently or inadequately.” The study also points to the multiplicity of programs, noting, for example, that “each military service and the Office of the Secretary of Defense administer dozens of family-focused prevention programs,” but “a more coordinated, comprehensive and systematic approach is needed.”

On Wednesday, the House Armed Services subcommittee on military personnel is scheduled to look into how the Defense Health Agency effort at jointness is moving ahead. Its director, Lt. Gen. Douglas J. Robb, and Jonathan Woodson, assistant secretary of defense for health affairs, will appear.

Joining them will be the GAO’s Brenda S. Farrell, whose agency has been critical of how the reforms are working.

For previous Fine Print columns, go to washingtonpost.com/fedpage.

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