Considerations Around the Use of Intensive Outpatient Programs for Service Members Who Experienced Sexual Trauma in the U.S. Military.

Section 702 of the fiscal year 2019 National Defense Authorization Act directed the U.S. Department of Defense (DoD) to conduct a pilot study to assess the feasibility and advisability of using intensive outpatient treatment programs to address posttraumatic stress disorder (PTSD) and associated mental health problems among service members who have experienced sexual harassment or sexual assault while in the military. RAND researchers conducted a programmatic review of four intensive outpatient programs (IOPs)-two in the private sector and two in DoD-to understand different program components available to active-duty service members who have suffered sexual trauma and other trauma. A review of policies to understand TRICARE authorization procedures and other regulations governing IOPs and an analysis of data from the 2014 RAND Military Workplace Study survey on the prevalence of sexual trauma among personnel with mental health conditions helped obtain contextual information to inform the Psychological Health Center of Excellence's response to Congress. The review identified evidence-based approaches that IOPs have successfully used in programs designed for military service members and barriers to using this type of care to treat members of the military community. While examining the IOP model of care, the research team identified knowledge gaps surrounding the experiences, treatment needs, and effectiveness of different treatment components and models of care for active-duty service members affected by the mental health consequences of sexual harassment and sexual assault in the military.

Evolution of Department of Defense Disability Evaluation and Management of Posttraumatic Stress Disorder and Traumatic Brain Injury: Overview of Policy Changes, 2001-2018.

For almost two decades, the United States has been engaged in continuous combat operations in Iraq, Afghanistan, and other theaters. Some service members have sustained injuries or developed medical conditions as a consequence of military service that affect their ability to perform their military duties. The process by which the U.S. Department of Defense (DoD) evaluates service members and determines whether they should be medically discharged has changed considerably since 2001. In particular, beginning in 2007, major changes to the Disability Evaluation System (DES) were implemented in response to concern about inefficiencies and confusion resulting from the practice of having DoD and the U.S. Department of Veterans Affairs (VA) conduct separate evaluations according to different criteria, thus producing different disability determinations. In 2008, DoD launched a pilot program to streamline the disability evaluation process, with VA conducting medical exams to be used by both DoD and VA. This system, the Integrated Disability Evaluation System (IDES), was formally adopted military-wide in 2011. Changes to DES also reflected changes in understanding of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), the signature injuries of the Iraq and Afghanistan wars. The authors review changes to disability evaluation policy and changes in the diagnosis and treatment of PTSD and TBI since 2001.

Integrating Department of Defense and Department of Veterans Affairs Purchased Care: Preliminary Feasibility Assessment.

The U.S. Department of Defense (DoD) and U.S. Department of Veterans Affairs (VA) health systems provide services through a mix of direct care, delivered at government facilities, and purchased care, provided through the private sector, mainly by community-based providers who have entered into contracts with third-party administrators (TPAs). In the interest of expanding DoD-VA resource sharing that may lead to greater efficiencies and cost savings, the DoD/VA Joint Executive Committee is exploring options to integrate DoD and VA's purchased care programs. This preliminary feasibility assessment examined how an integrated approach to purchasing care could affect access, quality, and costs for beneficiaries, DoD, and VA and identified general legislative, policy, and contractual challenges to implementing an integrated purchased care program. An integrated approach to purchasing care is feasible under current legal and regulatory authorities, but policy changes may be needed-and the practicality of such an approach depends on the contract and network design. For example, legal/regulatory changes in how contracts are established would be required to achieve any real savings to the government. There are also differences in the populations served by TRICARE (DoD health care) and VA, particularly in terms of age and geographic location. Implementation would be further complicated by contractual differences in the TPA contracts for VA and DoD as they relate to network standards, provider payments, network participation requirements, and reporting requirements and incentive structures. As a result, there are significant uncertainties with respect to increased efficiency or cost savings for the government.

Legal requirements and recommendations to prescribe naloxone.

BACKGROUND: The continued toll of opioid-related overdoses has motivated efforts to expand availability of naloxone to persons at high risk of overdose, with 2016 federal guidance encouraging clinicians to co-prescribe naloxone to patients with increased overdose risk. Some states have pursued analogous or stricter legal requirements that could more heavily influence prescriber behavior. METHODS: We conducted a systematic legal review of state laws that mandate or recommend that healthcare providers prescribe naloxone to patients with indicators for opioid overdose risk. We coded relevant statutes and regulations for: applicable populations, patient criteria, educational requirements, and exemptions. RESULTS: As of September 2019, 17 states had enacted naloxone co-prescribing laws, the earliest of which was implemented by Louisiana in January 2016. If patient overdose risk criteria are met, over half of these states mandate that providers prescribe naloxone (7 states, 41.1 %) or offer a naloxone prescription (2 states, 11.8 %); the remainder encourage prescribers to consider prescribing naloxone (8 states). Most states (58.8 %) define patient overdose risk based on opioid dosages prescribed, although the threshold varies substantially; other common overdose risk criteria include concomitant opioid and benzodiazepine prescriptions and patient history of substance use disorder or mental illness. CONCLUSIONS: A growing minority of states has adopted a naloxone prescribing law, although these policies remain less prevalent than other naloxone access laws. By targeting higher-risk patients during clinical encounters, naloxone prescribing requirements could increase naloxone prescribed, destigmatize naloxone use, and reduce overdose harms. Further investigation into policy effectiveness, unintended consequences, and appropriate parameters is warranted.

Authorities and Mechanisms for Purchased Care at the Department of Veterans Affairs.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the authorities and mechanisms by which the Department of Veterans Affairs (VA) pays for health care services from non-VA providers. Purchased care accounted for 10 percent, or around $5.6 billion, of VA's health care budget in fiscal year 2014, and the amount of care purchased from outside VA is growing rapidly. VA purchases non-VA care through an array of programs, each with different payment processes and eligibility requirements for veterans and outside providers. A review and analysis of statutes, regulations, legislation, and literature on VA purchased care, along with interviews with expert stakeholders, a survey of VA medical facilities, and an evaluation of local-level policy documents revealed that VA's purchased care system is complex and decentralized. Inconsistencies in procedures, unclear goals, and a lack of cohesive strategy for purchased care could have ramifications for veterans' access to care. Adding to the complexity of VA's purchased care system is a lack of systematic data collection on access to and quality of care provided through VA's purchased care programs. The analysis also explored concepts of "episodes of care" and their implications for purchased care by VA.