Background

Since the onset of OIF and OEF, over 1 million servicemembers have been  deployed. As of the end of June 2005, more than 393,000 active duty,  Reserve, and National Guard servicemembers from OIF and OEF have  separated from active duty. Of these, over 100,000 have sought health care  services from VA, including over 2,400 who received inpatient care at VA  medical centers. The Reserves and National Guard account for about  54,000 of those servicemembers who sought health care services from VA.  The three most common health problems have been musculoskeletal  ailments (primarily joint and back disorders), dental problems, and mental  health disorders.
Servicemembers injured during OIF and OEF are surviving injuries that  would have been fatal in past conflicts. In World War II, 30 percent of  Americans injured in combat died; this proportion dropped to 24 percent  for those injured in the Vietnam War and further dropped to about   10 percent for those injured in OIF and OEF. Many of the injured OIF and  OEF servicemembers are returning with severe disabilities, including  traumatic brain injuries and missing limbs.
About 65 percent of OIF and OEF combat injuries are from improvised  explosive devices, blasts, landmines, and fragments. Of those injured  personnel, about 60 percent have some degree of traumatic brain injury  and may require comprehensive inpatient rehabilitation services to  address complex cognitive, physical, and mental health issues resulting  from trauma. Traumatic brain injuries may cause problems with cognition  (concentration, memory, judgment, and mood), movement (strength,  coordination, and balance), sensation (tactile sensation and vision), and  emotion (instability and impulsivity). The Department of Health and  Human Services’ Centers for Disease Control and Prevention reports that  an estimated 15 percent of persons who sustain a mild brain injury  continue to experience symptoms 1 year after injury.
Initially, most severely injured servicemembers, including Reserve and  National Guard members, are brought to Landstuhl Regional Medical  Center in Germany for treatment. From there, they are transported to  appropriate U.S. military medical facilities, with most of the seriously  injured admitted to Walter Reed Army Medical Center or the National  Naval Medical Center, both located in the Washington, D.C., area. Once  these servicemembers are medically stabilized, many are relocated closer  to their homes or military commands and continue recovering either on an  inpatient or outpatient basis at a VA medical facility, a DOD military  treatment facility (MTF), or DOD civilian provider.
Those who have served, or are now serving, in OIF and OEF may receive  care from VA for conditions that are or may be related to their combat  services for a 2-year period following the date of their separation from  active duty without copayment requirements. Following this 2-year period,  they may continue to receive VA care but may be subject to a copayment  for their health care.
To ensure that servicemembers engaged in conflicts receive the health  care services they need, Congress passed legislation in May 1982 that  authorized VA to provide medical services to members of the armed forces  during and immediately following wartime or national emergencies  involving the armed forces in armed conflict. The law authorized the  Secretary of VA to give servicemembers responding to or involved in a war  or national emergency a higher priority for medical services than all  veterans, except those with a service-connected disability. VA has  established an enrollment system to manage veterans’ access to care. This  system includes eight priority categories for enrollment, with higher  priority given to veterans with service-connected disabilities, lower  incomes, or other recognized statuses such as former prisoners of war.
Separation from the military and return to civilian life may entail the  exchange of individually identifiable health information between DOD and  VA. The exchange of this information must comply with the Health  Insurance Portability and Accountability Act of 1996 (HIPAA) and the  HIPAA Privacy Rule, which became effective April 14, 2001. The HIPAA  Privacy Rule permits DOD and VA to share servicemembers’ health  information under certain circumstances, such as for continuity of health  care treatment or if the individual signs a proper authorization.

		VA Has Established Policies and Outreach Efforts Intended to Smooth the Transition from DOD Health Care

VA has taken several steps to provide OIF and OEF servicemembers with  timely access to health care and information on health care services.  These steps include setting policies and developing outreach efforts  targeting OIF and OEF servicemembers.

			Recent VA Policies Designed to Facilitate Transition to VA Health Care

Since 2002, VA has issued a memorandum and four directives addressing  eligibility criteria and the health care needs of recently discharged  servicemembers.
A September 2002 directive established policies and procedures for  offering hospital care, medical services, and nursing home care to recently  discharged servicemembers for a 2-year period, beginning on their  discharge date, for any illness, without requiring proof of its link to  military service. Under this directive, these veterans are enrolled in the  lowest priority category for service-connected veterans.  In April 2003, when the President declared a national emergency with  respect to the conflict in Iraq, the Secretary of VA issued a memorandum  authorizing VA to give priority health care to servicemembers who  sustained an injury, over veterans and others eligible for VA care, except  those with service-connected disabilities.
An October 2003 directive (1) provided instructions to VA employees for  determining the eligibility of recent combat veterans to be enrolled for VA  health care; (2) required each VA medical facility to designate a clinically  trained combat case manager, usually a social worker or nurse, to  coordinate all of the medical care and services provided to recent combat  veterans by VA and non-VA agencies until the veterans no longer need  care; and (3) required VA medical facilities to designate a point of  contact—administrative staff, social worker, or nurse—to receive and  expedite transfers of servicemembers from MTFs to VA medical facilities  and coordinate with VA’s combat case managers.
A June 2005 directive specified the dates of service and combat locations  to determine whether recent combat veterans are eligible for health care  services.
Another June 2005 directive expanded the scope of care at VA’s four  regional traumatic brain injury rehabilitation centers and redefined these  facilities as polytrauma rehabilitation centers. These centers’ inclusion of  psychological treatment for family members and rehabilitation services  using high-technology prosthetics reflect VA’s intention to provide more  coordinated care for patients, including the growing number of OIF and  OEF servicemembers with severe and disabling trauma. The directive  states that coordination of care, including intensive clinical and social  work case management services, is essential in these severe trauma  cases, as patients transition from acute hospitalization through acute  rehabilitation and ultimately to their home communities.
In addition to VA’s directives, a joint DOD and VA program was  established in August 2003 to assign VA social workers to selected MTFs  to coordinate patient transfers between MTFs and VA medical facilities.  The social workers make appointments for care, ensure continuity of  therapy and medications, and followup with patients to verify success of  the discharge. By mid-July 2005, the social workers had received 3,907  requests for transfer of care—almost two-thirds of them had been  transferred to VA facilities; the rest were pending. Further, VA benefits  counselors work with the social workers to inform servicemembers about  VA benefits and to initiate paperwork for disability compensation claims,  vocational rehabilitation and employment assistance, and other VA  benefits.
Also in August 2003, VA created the Taskforce for the Seamless Transition  of Returning Service Members. The taskforce, composed of senior VA  leadership, focused on developing and implementing VA policies to  improve the transition of injured servicemembers to civilian life. In  January 2005, VA established the Seamless Transition Office to further  improve coordination within the Veterans Benefits Administration and the  Veterans Health Administration as well as between DOD and VA. The  goals of the Seamless Transition Office include improving communication,  coordination, and collaboration within VA and with DOD with respect to  health care; educating VA staff about veteran’s health care and other  needs; and ensuring that policies and procedures are in place to enhance  the transition from servicemember to veteran. The Seamless Transition  Office uses the taskforce in an advisory capacity.
To help ensure that VA staff assisting OIF and OEF servicemembers can  be responsive to their health care needs, the agency created an internal  Web site to provide a single source of access to VA policies, procedures,  and directives for wounded, ill, and seriously injured servicemembers and  veterans. According to VA, the internal Web site also includes a list of the  points of contact at medical facilities and articles about transition-related  activities.

			VA Outreach Efforts to OIF and OEF Servicemembers

VA has instituted several outreach strategies to provide information about  the health care services available to OIF and OEF servicemembers who  have been discharged. These include the use of newsletters, personal  letters, an external Web site, counseling services, and briefings on VA  benefits and services.
Using DOD rosters of OIF and OEF servicemembers who have separated  from active duty, VA sends newsletters and personal letters with pertinent  information to these new veterans. VA has sent three newsletters since  December 2003, with information on benefits and health issues specific to  OIF and OEF veterans. In addition, the Secretary of VA sends these new  veterans a letter thanking them for their service to the country and  informing them about VA health care services and assistance to aid in their  transition to civilian life. The letter includes a toll-free number for  obtaining information on VA health care and two brochures on VA health  care as well as benefit information, including disability compensation,  education and training, vocational rehabilitation and employment, home  loans, and life insurance. In addition, the Secretary of VA has sent letters  to all the Adjutants General and Chiefs of the Reserves to inform them of  VA services and benefits.
VA has also sought to improve access to health care information. It  created a Web site that provides information specific to those who served  in OIF and OEF, such as information on VA health and medical services;  dependents’ benefits and services; transition assistance; and benefits for  active duty military, Reserve, and National Guard personnel. In addition,  VA developed a wallet-sized card with relevant toll-free telephone  numbers and Web site addresses. VA officials reported that the agency has  distributed 1 million copies of this wallet card.
VA has enhanced outreach to those who served in OIF and OEF and their  families through its Vet Center Readjustment Counseling Service,  consisting of 207 centers. Vet Centers function as community points of  access by providing information and referrals to VA medical facilities.  Additionally, they offer counseling, employment services, and a range of  social services to assist individuals in readjusting from wartime military  service to civilian life. VA reported that during 2004, it hired 50 peer  counselors and placed them at Vet Centers where significant numbers of  servicemembers were returning from OIF and OEF. According to a VA  official, VA is in the process of hiring an additional 50 peer counselors.
Briefings are another form of outreach used by VA to inform OIF and OEF  servicemembers about health care services.
From fiscal year 2001 through the third quarter of fiscal year 2005, VA held  more than 30,800 briefings on VA benefits for more than 1.1 million  servicemembers. These briefings include about 3,700 predeployment and  postdeployment briefings for about 230,000 activated Reserve and  National Guard servicemembers.
For OIF and OEF servicemembers who may potentially use VA  services, DOD and VA share some types of administrative data, such as  individuals’ names and addresses; however, the sharing of health  information between the two departments remains limited.
VA could not report how many of these were OIF and OEF servicemembers.
MOU for the sharing of individually identifiable health information. The  MOU constitutes an agreement on the circumstances under which DOD  and VA will exchange individually identifiable health information and  includes references to provisions of the HIPAA Privacy Rule and  applicable laws that permit sharing. The MOU does not specify particular  types of individually identifiable heath information that will be exchanged  and when the information will be shared. The absence of specific data  sharing procedures continues to hinder VA’s efforts to obtain needed  health information from DOD.
For example, DOD does not have specific procedures to routinely provide  VA with health information on servicemembers who have injuries or  illnesses that preclude them from continuing on active duty and, as a  result, are being evaluated by a DOD physical evaluation board (PEB) for  separation from the military. According to VA officials, if a list of these  individuals were transmitted routinely to VA, it would enable VA to  contact the individuals to make the appropriate transfer of health care to a  VA medical facility before the individuals are discharged from the military.  Such information could reduce the potential for interruption to these  individuals’ health care treatment plans. DOD officials told us that they are  in the process of developing a policy directive that would establish  procedures for sharing information with VA on servicemembers who are  entering the PEB process, but they could not determine when this policy  directive would become effective.
Recent progress in VA and DOD data sharing involves a health assessment  questionnaire that DOD requires servicemembers to complete following  deployment. This document contains, among other things, self-reported  information about a servicemember’s potential exposure to toxic  substances and includes four questions that can be used to identify  individuals at risk of developing post-traumatic stress disorder. In July  2005, DOD transmitted to VA postdeployment health assessment data for  those individuals who have been discharged from the military. According  to VA officials, DOD is expected to transmit these data monthly beginning  in October 2005. For these individuals, VA clinicians will be able to access  the data through VA’s computerized medical record system when the  individuals seek VA health care services. However, according to VA  officials, DOD is not providing health assessment information to VA for  Reserve and National Guard members, who comprise 35 percent of the  OIF and OEF forces.
In addition to individual health information from the postdeployment  questionnaire, VA officials state that the agency could use aggregate data  from the questionnaire to plan for the needs of current servicemembers  who may one day be eligible for health care and benefits from VA. This is  consistent with an observation made by the President’s task force that  comprehensive servicemember health data are essential for forecasting  and preparing for changes in the demand for health care services.  Currently, the data from the individual postdeployment assessments are  not accessible in a format that can be aggregated and manipulated to  provide the desired trend information.
Mr. Chairman, this concludes my prepared remarks. I will be pleased to  answer any questions you or other members of the committee may have.

	Contacts and Acknowledgments

For further information regarding this testimony, please contact   Cynthia A. Bascetta at (202) 512-7101 or bascettac@gao.gov.   Michael T. Blair, Jr., Assistant Director; Mary Ann Curran; Hannah Fein;  Cynthia Forbes; Marcia Mann; Kevin Milne; and Cherie Starck also  contributed to this statement.

Related GAO Products

Military and Veterans’ Benefits: Improvements Needed in Transition  Assistance Services for Reserves and National Guard. GAO-05-844T.  Washington, D.C.: June 29, 2005.
Military and Veterans’ Benefits: Enhanced Services Could Improve  Transition Assistance for Reserves and National Guard. GAO-05-544.  Washington, D.C.: May 20, 2005.
DOD and VA: Systematic Data Sharing Would Help Expedite  Servicemembers’ Transition to VA Services. GAO-05-722T. Washington,  D.C.: May 19, 2005.
Vocational Rehabilitation: VA Has Opportunities to Improve Services,  but Faces Significant Challenges. GAO-05-572T. Washington, D.C.:   April 20, 2005.
VA Disability Benefits and Health Care: Providing Certain Services to  the Seriously Injured Poses Challenges. GAO-05-444T. Washington, D.C.:  March 17, 2005.
Vocational Rehabilitation: More VA and DOD Collaboration Needed to  Expedite Services for Severely Injured Servicemembers. GAO-05-167.  Washington, D.C.: January 14, 2005.
VA and Defense Health Care: More Information Needed to Determine if  VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder  Services. GAO-04-1069. Washington, D.C.: September 20, 2004.
Major Management Challenges and Program Risks: Department of  Veterans Affairs. GAO-03-110. Washington, D.C.: January 2003.
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Summary:
Why GAO Did This Study

Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) servicemembers and those who are discharged from military service may receive health care from the Department of Veterans Affairs (VA). Since the onset of OIF and OEF, the Department of Defense (DOD) has reported that more than 15,000 servicemembers have been wounded in combat. Those who are seriously injured require comprehensive health care services and may be treated at either DOD or VA medical facilities. Because VA is expected to provide health care to many of the injured OIF and OEF servicemembers, concerns have been raised about the ease with which these individuals and their health care information transition from DOD's to VA's health care system. This statement is based on GAO's preliminary work on "seamless transition" and focuses on (1) the policies and outreach efforts that VA has instituted to provide timely access to health care to OIF and OEF servicemembers and (2) the extent to which individually identifiable health information is shared systematically between DOD and VA. Since GAO's work is still in the early stages of review, the statement is limited to information gathered to date.

What GAO Found

Since 2002, VA has developed policies and procedures that direct its medical facilities to provide OIF and OEF servicemembers timely access to care. Most notably, VA assigned VA social workers to selected military treatment facilities in August 2003, directed VA facilities to designate combat case managers in October 2003, and directed the establishment of four VA polytrauma centers for OIF and OEF servicemembers in June 2005. In January 2005, VA established the Seamless Transition Office to further improve coordination within the Veterans Benefits Administration and the Veterans Health Administration as well as between DOD and VA. In addition, VA has increased outreach efforts by providing OIF and OEF servicemembers who have been discharged with personal letters and newsletters, a Web site for health information tailored to OIF and OEF servicemembers, counseling services, and briefings on available VA health care services. GAO is in the beginning stages of reviewing VA's efforts to provide a smooth transition from DOD health care and has not yet evaluated the effectiveness of VA's related policies, procedures, and outreach initiatives. An important issue associated with transitioning servicemembers to VA health care is the sharing of health care information between DOD and VA. The two departments have signed a memorandum of understanding for sharing individually identifiable health information, but the memorandum does not specify the particular types of individually identifiable health information that will be exchanged and when the information will be shared. The absence of specific procedures continues to hinder VA's efforts to obtain needed health information from DOD. Recently, DOD has begun to share certain health assessment information with VA on individuals who have been discharged from the military, and the transmitting of this information to VA on a routine basis is expected to occur in October 2005. However, according to VA officials, DOD is not providing health assessment information to VA for Reserve and National Guard members, who comprise 35 percent of the OIF and OEF forces.