DOD and VA Health Care: Challenges Encountered by Injured Servicemembers during Their Recovery Process
Published: 2007-03-08T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: As of March 1, 2007, over 24,000 servicemembers have been wounded in action since the onset of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), according to the Department of Defense (DOD). GAO work has shown that servicemembers injured in combat face an array of significant medical and financial challenges as they begin their recovery process in the health care systems of DOD and the Department of Veterans Affairs (VA). GAO was asked to discuss concerns regarding DOD and VA efforts to provide medical care and rehabilitative services for servicemembers who have been injured during OEF and OIF. This testimony addresses (1) the transition of care for seriously injured servicemembers who are transferred between DOD and VA medical facilities, (2) DOD's and VA's efforts to provide early intervention for rehabilitation for seriously injured servicemembers, (3) DOD's efforts to screen servicemembers at risk for post-traumatic stress disorder (PTSD) and whether VA can meet the demand for PTSD services, and (4) the impact of problems related to military pay on injured servicemembers and their families. This testimony is based on GAO work issued from 2004 through 2006 on the conditions facing OEF/OIF servicemembers at the time the audit work was completed.
section_title: What GAO Found
paragraphs: Despite coordinated efforts, DOD and VA have had problems sharing medical records for servicemembers transferred from DOD to VA medical facilities. GAO reported in 2006 that two VA facilities lacked real-time access to electronic medical records at DOD facilities. To obtain additional medical information, facilities exchanged information by means of a time-consuming process resulting in multiple faxes and phone calls. In 2005, GAO reported that VA and DOD collaboration is important for providing early intervention for rehabilitation. VA has taken steps to initiate early intervention efforts, which could facilitate servicemembers' return to duty or to a civilian occupation if the servicemembers were unable to remain in the military. However, according to DOD, VA's outreach process may overlap with DOD's process for evaluating servicemembers for a possible return to duty. DOD was also concerned that VA's efforts may conflict with the military's retention goals. In this regard, DOD and VA face both a challenge and an opportunity to collaborate to provide better outcomes for seriously injured servicemembers. DOD screens servicemembers for PTSD but, as GAO reported in 2006, it cannot ensure that further mental health evaluations occur. DOD health care providers review questionnaires, interview servicemembers, and use clinical judgment in determining the need for further mental health evaluations. However, GAO found that 22 percent of the OEF/OIF servicemembers in GAO's review who may have been at risk for developing PTSD were referred by DOD health care providers for further evaluations. According to DOD officials, not all of the servicemembers at risk will need referrals. However, at the time of GAO's review DOD had not identified the factors its health care providers used to determine which OEF/OIF servicemembers needed referrals. Although OEF/OIF servicemembers may obtain mental health evaluations or treatment for PTSD through VA, VA may face a challenge in meeting the demand for PTSD services. VA officials estimated that follow-up appointments for veterans receiving care for PTSD may be delayed up to 90 days. GAO's 2006 testimony pointed out problems related to military pay have resulted in debt and other hardships for hundreds of sick and injured servicemembers. Some servicemembers were pursued for repayment of military debts through no fault of their own. As a result, servicemembers have been reported to credit bureaus and private collections agencies, been prevented from getting loans, gone months without paychecks, and sent into financial crisis. In a 2005 testimony GAO reported that poorly defined requirements and processes for extending the active duty of injured and ill reserve component servicemembers have caused them to be inappropriately dropped from active duty, leading to significant gaps in pay and health insurance for some servicemembers and their families.

section_title: Letter
paragraphs: I am pleased to be here today to discuss health care and other services for  U.S. military servicemembers wounded during Operation Enduring  Freedom (OEF) or Operation Iraqi Freedom (OIF). On March 1, 2007, the  Department of Defense (DOD) reported that over 24,000 servicemembers  have been wounded in action since the onset of the two conflicts. In 2005,  DOD reported that about 65 percent of the OEF and OIF servicemembers  wounded in action were injured by blasts and fragments from improvised  explosive devices, land mines, and other explosive devices. More recently,  DOD estimated in 2006 that as many as 28 percent of those injured by  blasts and fragments have some degree of trauma to the brain. These  injuries often require comprehensive inpatient rehabilitation services to  address complex cognitive and physical impairments. In addition to their  physical injuries, OEF/OIF servicemembers who have been injured in  combat may also be at risk for developing mental health impairments,  such as post-traumatic stress disorder (PTSD), which research has shown  to be strongly associated with experiencing intense and prolonged  combat.
While servicemembers are on active duty, DOD decides where they  receive their care—at a military treatment facility (MTF), from a TRICARE  civilian provider, or at a Department of Veterans Affairs (VA) medical  facility. From the OEF and OIF conflict areas, seriously injured  servicemembers are usually brought to Landstuhl Regional Medical Center  in Germany for treatment. From there, they are usually transported to  MTFs located in the United States, with most of the seriously injured  admitted to Walter Reed Army Medical Center or the National Naval  Medical Center, both of which are in the Washington, D.C., area. Once the  servicemembers are medically stabilized, DOD can elect to send those  with traumatic brain injuries and other complex trauma, such as missing  limbs, to one of the four polytrauma rehabilitation centers (PRC)  operated by VA for medical and rehabilitative care. The PRCs are located  at VA medical centers in Palo Alto, California; Tampa, Florida;  Minneapolis, Minnesota; and Richmond, Virginia. While many  servicemembers who receive such rehabilitative services return to active  duty after they are treated, others who are more seriously injured are  likely to be discharged from their military obligations and return to civilian  life with disabilities.
Our work has shown that servicemembers injured in combat face an array  of significant medical and financial challenges as they begin their recovery  process in the DOD and VA health care systems. In light of these  challenges and recent media reports that have highlighted unsanitary and  decrepit living conditions at the Walter Reed Army Medical Center, you  asked us to discuss concerns we have identified regarding DOD and VA  efforts to provide medical care and rehabilitative services for  servicemembers who have been injured during OEF and OIF. Specifically,  my remarks today will focus on (1) the transition of care for seriously  injured OEF/OIF servicemembers—those with traumatic brain injuries or  other complex trauma, such as missing limbs—who are transferred  between DOD and VA medical facilities; (2) DOD’s and VA’s efforts to  provide early intervention for rehabilitation services as soon as possible  after the onset of a disability for seriously injured servicemembers;   (3) DOD’s efforts to screen OEF/OIF servicemembers at risk for PTSD and  whether VA can meet the demand for PTSD services; and (4) the impact of  problems related to military pay on injured servicemembers and their  families.
My testimony is based on issued GAO work. The information I am  reporting today reflects the conditions facing OEF/OIF servicemembers at  the time the audit work was completed and illustrates the types of  problems injured servicemembers encountered during their healing and  rehabilitation process. To complete the work for these products, we  visited DOD and VA facilities, reviewed relevant documents, analyzed  DOD data, and interviewed DOD and VA officials. Our work was  performed in accordance with generally accepted government auditing  standards.
In summary, DOD and VA have made various efforts to provide medical  care and rehabilitative services for OEF/OIF servicemembers. The  departments established joint programs to facilitate the transfer of injured  servicemembers from DOD facilities to VA medical facilities, assess  whether servicemembers will be able to remain in the military, and assign  VA social workers to selected MTFs to coordinate the transfers. DOD has  also established a program to screen servicemembers after their  deployment outside of the United States has ended to assess whether they  are at risk for PTSD. However, we found several problems in the efforts to  provide health care and rehabilitative services for OEF/OIF  servicemembers. For example, DOD and VA had problems sharing medical  records and questions arose about the timing of VA’s outreach to  servicemembers whose discharge from military service was not certain.  Furthermore, we found that DOD cannot provide reasonable assurance  that OEF/OIF servicemembers who need referrals for mental health  evaluations receive them. Finally, problems related to military pay have  resulted in overpayments and debt for hundreds of sick and injured  servicemembers.
subsections: section_title: DOD and VA Have Taken Actions to Facilitate the Transfer of Servicemembers but Experienced Problems in Exchanging Health Care Information
paragraphs: In our June 2006 report, we found that DOD and VA had taken actions to  facilitate the transition of medical and rehabilitative care for seriously  injured servicemembers who were being transferred from MTFs to PRCs.  For example, in April 2004, DOD and VA signed a memorandum of  agreement that established referral procedures for transferring injured  servicemembers from DOD to VA medical facilities. DOD and VA also  established joint programs to facilitate the transfer to VA medical  facilities, including a program that assigned VA social workers to selected  MTFs to coordinate transfers.
Despite these coordination efforts, we found that DOD and VA were  having problems sharing the medical records VA needed to determine  whether servicemembers’ medical conditions allowed participation in VA’s  vigorous rehabilitation activities. DOD and VA reported that as of  December 2005 two of the four PRCs had real-time access to the electronic  medical records maintained at Walter Reed Army Medical Center and only  one of the two also had access to the records at the National Naval  Medical Center. In cases where medical records could not be accessed  electronically, the MTF faxed copies of some medical information, such as  the patient’s medical history and progress notes, to the PRC. Because this  information did not always provide enough data for the PRC provider to  determine if the servicemember was medically stable enough to be  admitted to the PRC, VA developed a standardized list of the minimum  types of health care information needed about each servicemember  transferring to a PRC. Even with this information, PRC providers  frequently needed additional information and had to ask for it specifically.  For example, if the PRC provider notices that the servicemember is on a  particular antibiotic therapy, the provider may request the results of the  most recent blood and urine cultures to determine if the servicemember is  medically stable enough to participate in strenuous rehabilitation  activities. According to PRC officials, obtaining additional medical  information in this way, rather than electronically, is very time consuming  and often requires multiple phone calls and faxes. VA officials told us that  the transfer could be more efficient if PRC medical personnel had real- time access to the servicemembers’ complete DOD electronic medical  records from the referring MTFs. However, problems existed even for the  two PRCs that had been granted electronic access. During a visit to those  PRCs in April 2006, we found that neither facility could access the records  at Walter Reed Army Medical Center because of technical difficulties.
section_title: DOD and VA Collaboration Is Important for Early Intervention for Rehabilitation
paragraphs: As discussed in our January 2005 report, the importance of early  intervention for returning individuals with disabilities to the workforce is  well documented in vocational rehabilitation literature. In 1996, we  reported that early intervention significantly facilitates the return to work  but that challenges exist in providing services early. For example,  determining the best time to approach recently injured servicemembers  and gauge their personal receptivity to considering employment in the  civilian sector is inherently difficult. The nature of the recovery process is  highly individualized and requires professional judgment to determine the  appropriate time to begin vocational rehabilitation. Our 2007 High-Risk  Series: An Update designates federal disability programs as “high risk”  because they lack emphasis on the potential for vocational rehabilitation  to return people to work.
In our January 2005 report, we found that servicemembers whose  disabilities are definitely or likely to result in military separation may not  be able to benefit from early intervention because DOD and VA could  work at cross purposes. In particular, DOD was concerned about the  timing of VA’s outreach to servicemembers whose discharge from military  service is not yet certain. DOD was concerned that VA’s efforts may  conflict with the military’s retention goals. When servicemembers are  treated as outpatients at a VA or military hospital, DOD generally begins to  assess whether the servicemember will be able to remain in the military.  This process can take months. For its part, VA took steps to make  seriously injured servicemembers a high priority for all VA assistance.  Noting the importance of early intervention, VA instructed its regional  offices in 2003 to assign a case manager to each seriously injured  servicemember who applies for disability compensation. VA had detailed  staff to MTFs to provide information on all veterans’ benefits, including  vocational rehabilitation, and reminded staff that they can initiate  evaluation and counseling, and, in some cases, authorize training before a  servicemember is discharged. While VA tries to prepare servicemembers  for a transition to civilian life, VA’s outreach process may overlap with  DOD’s process for evaluating servicemembers for a possible return to  duty.
In our report, we concluded that instead of working at cross purposes to  DOD goals, VA’s early intervention efforts could facilitate servicemembers’  return to the same or a different military occupation, or to a civilian  occupation if the servicemembers were not able to remain in the military.  In this regard, the prospect for early intervention with vocational  rehabilitation presents both a challenge and an opportunity for DOD and  VA to collaborate to provide better outcomes for seriously injured  servicemembers.
section_title: DOD Screens Servicemembers for PTSD after Deployment, but DOD and VA Face Challenges Ensuring Further PTSD Services
paragraphs: In our May 2006 report, we described DOD’s efforts to identify and  facilitate care for OEF/OIF servicemembers who may be at risk for PTSD.  To identify such servicemembers, DOD uses a questionnaire, the DD 2796,  to screen OEF/OIF servicemembers after their deployment outside of the  United States has ended. The DD 2796 is used to assess servicemembers’  physical and mental health and includes four questions to identify those  who may be at risk for developing PTSD. We reported that according to a  clinical practice guideline jointly developed by DOD and VA,  servicemembers who responded positively to at least three of the four  PTSD screening questions may be at risk for developing PTSD. DOD health  care providers review completed questionnaires, conduct face-to-face  interviews with servicemembers, and use their clinical judgment in  determining which servicemembers need referrals for further mental  health evaluations. OEF/OIF servicemembers can obtain the mental  health evaluations, as well as any necessary treatment for PTSD, while  they are servicemembers—that is, on active duty—or when they transition  to veteran status if they are discharged or released from active duty.
Despite DOD’s efforts to identify OEF/OIF servicemembers who may need  referrals for further mental health evaluations, we reported that DOD  cannot provide reasonable assurance that OEF/OIF servicemembers who  need the referrals receive them. Using data provided by DOD, we found  that 22 percent, or 2,029, of the 9,145 OEF/OIF servicemembers in our  review who may have been at risk for developing PTSD were referred by  DOD health care providers for further mental health evaluations. Across  the military service branches, DOD health care providers varied in the  frequency with which they issued referrals to OEF/OIF servicemembers  with three or more positive responses to the PTSD screening questions------ the Army referred 23 percent, the Air Force about 23 percent, the Navy   18 percent, and the Marines about 15 percent. According to DOD officials,  not all of the OEF/OIF servicemembers with three or four positive  responses on the screening questionnaire need referrals. As directed by  DOD’s guidance for using the DD 2796, DOD health care providers are to  rely on their clinical judgment to decide which of these servicemembers  need further mental health evaluations. However, at the time of our review  DOD had not identified the factors its health care providers used to  determine which OEF/OIF servicemembers needed referrals. Knowing  these factors could explain the variation in referral rates and allow DOD to  provide reasonable assurance that such judgments are being exercised  appropriately. We recommended that DOD identify the factors that DOD  health care providers used in issuing referrals for further mental health  evaluations to explain provider variation in issuing referrals. DOD  concurred with the recommendation.
Although OEF/OIF servicemembers may obtain mental health evaluations  or treatment for PTSD through VA when they transition to veteran status,  VA may face a challenge in meeting the demand for PTSD services. In  September 2004 we reported that VA had intensified its efforts to inform  new veterans from the Iraq and Afghanistan conflicts about the health care  services—including treatment for PTSD—VA offers to eligible veterans.  We observed that these efforts, along with expanded availability of VA  health care services for Reserve and National Guard members, could  result in an increased percentage of veterans from Iraq and Afghanistan  seeking PTSD services through VA. However, at the time of our review  officials at six of seven VA medical facilities we visited explained that  while they were able to keep up with the current number of veterans  seeking PTSD services, they may not be able to meet an increase in  demand for these services. In addition, some of the officials expressed  concern because facilities had been directed by VA to give veterans from  the Iraq and Afghanistan conflicts priority appointments for health care  services, including PTSD services. As a result, VA medical facility officials  estimated that follow-up appointments for veterans receiving care for  PTSD could be delayed. VA officials estimated the delays to be up to   90 days.
section_title: Problems Related to Military Pay Have Resulted in Debt and Other Hardships for Hundreds of Sick and Injured Servicemembers
paragraphs: As discussed in our April 2006 testimony, problems related to military pay  have resulted in overpayments and debt for hundreds of sick and injured  servicemembers. These pay problems resulted in significant frustration  for the servicemembers and their families. We found that hundreds of  battle-injured servicemembers were pursued for repayment of military  debts through no fault of their own, including at least 74 servicemembers  whose debts had been reported to credit bureaus and private collections  agencies. In response to our audit, DOD officials said collection actions on  these servicemembers’ debts had been suspended until a determination  could be made as to whether these servicemembers’ debts were eligible  for relief.
Debt collection actions created additional hardships on servicemembers  by preventing them from getting loans to buy houses or automobiles or  pay off other debt, and sending several servicemembers into financial  crisis. Some battle-injured servicemembers forfeited their final separation  pay to cover part of their military debt, and they left the service with no  funds to cover immediate expenses while facing collection actions on their  remaining debt.
We also found that sick and injured servicemembers sometimes went  months without paychecks because debts caused by overpayments of  combat pay and other errors were offset against their military pay.  Furthermore, the longer it took DOD to stop the overpayments, the greater  the amount of debt that accumulated for the servicemember and the  greater the financial impact, since more money would eventually be  withheld from the servicemember’s pay or sought through debt collection  action after the servicemember had separated from the service.
In our 2005 testimony about Army National Guard and Reserve  servicemembers, we found that poorly defined requirements and  processes for extending injured and ill reserve component  servicemembers on active duty have caused servicemembers to be  inappropriately dropped from active duty. For some, this has led to  significant gaps in pay and health insurance, which has created financial  hardships for these servicemembers and their families.
Mr. Chairman, this completes my prepared remarks. I would be happy to  respond to any questions you or other members of the subcommittee may  have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For further information about this testimony, please contact Cynthia A.  Bascetta at (202) 512-7101 or bascettac@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Michael T. Blair, Jr., Assistant Director;  Cynthia Forbes; Krister Friday; Roseanne Price; Cherie’ Starck; and  Timothy Walker made key contributions to this statement.
section_title: Related GAO Products
paragraphs: High-Risk Series: An Update. GAO-07-310. Washington, D.C.: January  2007.
VA and DOD Health Care: Efforts to Provide Seamless Transition of  Care for OEF and OIF Servicemembers and Veterans. GAO-06-794R.  Washington, D.C.: June 30, 2006.
Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its  Providers Use to Make Mental Health Evaluation Referrals for  Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006.
Military Pay: Military Debts Present Significant Hardships to Hundreds  of Sick and Injured GWOT Soldiers. GAO-06-657T. Washington, D.C.:   April 27, 2006.
Military Disability System: Improved Oversight Needed to Ensure  Consistent and Timely Outcomes for Reserve and Active Duty Service  Members. GAO-06-362. Washington, D.C.: March 31, 2006.
Military Pay: Gaps in Pay and Benefits Create Financial Hardships for  Injured Army National Guard and Reserve Soldiers. GAO-05-322T.  Washington, D.C.: February 17, 2005.
Vocational Rehabilitation: More VA and DOD Collaboration Needed to  Expedite Services for Seriously 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.
SSA Disability: Return-to-Work Strategies from Other Systems May  Improve Federal Programs. GAO/HEHS-96-133. Washington, D.C.: July 11,  1996.
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