Considerations for Retrograding Deployed Army Pharmacy Operations: What about Department of Defense Civilian Contractors? Lessons from Kosovo

Considerations for Retrograding Deployed Army Pharmacy Operations: What about Department of... Abstract Background Over the past two decades, changes in mission and expectations of deployed medical assets are requiring adaptations of pharmacy services. Specifically, the Department of Defense (DOD)-deployed contractors in theater are now eligible for varying levels of care from DOD-deployed assets. Pharmacy must now stock and maintain a complex medication footprint. This new requirement makes the attempt to retrograde a long established deployed pharmacy difficult and presents new challenges. Methods We review the issues surrounding this quandary from the perspective of the deployed pharmacy in Kosovo, one of the longest standing theaters of deployed medical assets. Findings Data from the 20th and 21st medical rotations in this theater demonstrate that DOD contractors consume a significant portion of pharmacy operational support. However, not only do contractors increase the volume but also pharmacy must address the use and monitoring of complex medications such as anticoagulants, antidiabetics, sleep, and psychiatric medications, as well as chronic obstructive pulmonary disease and asthma drugs, which are not typical in the deployed environment. Discussion/Impact/Recommendations Contractors are now serving in the Balkan theater at a greater than 1:1 ratio of contractors to soldiers. Contractors are typically older than deployed soldiers and thus their pharmaceutical needs are more complex. This complicates the pharmacy operation, which on the one hand is trying to retrograde as the mission winds down, yet, on the other hand, must expand to more complex operations to support the DOD contractors in theater. INTRODUCTION Army pharmacy is proficient at deploying to theater as well as starting and maintaining pharmacy operations to meet the initial and sustained mission requirements. However, published literature is limited regarding how pharmacy services terminate as the overall Department of Defense (DOD) mission winds down. Newer considerations such as DOD contractor support and the management of their health care has been less studied. We look at the example from the pharmacy in Kosovo, which has been deployed in the Balkan theater of operations for nearly 20 yr. Contractors there and elsewhere are often dependent on DOD pharmacy for their prescription needs, and nowhere has this become more evident than in Kosovo. Force management issues such as Force Caps have necessitated a greater than 1:1 ratio of contractors to soldiers in the Balkans theater, thereby complicating the mission of the pharmacy. Initially, the thought was that the DOD contractors arriving from the USA would do similar jobs as soldiers in theater and have similar pharmaceutical needs. Thus, their contracts often stipulate such a provision. However, it has become apparent that contractors from the USA are often older and many are in their sixth or seventh decade of life and more in need of a full service pharmacy than the typical deployed soldier. Further, the Soldier Readiness Process, a requirement for all deploying, appears less rigorous for DOD contractors than for soldiers. Contractors arrive and remain in theater with multiple comorbidities that are not consistent with available care to manage their chronic conditions. This conundrum is explored briefly, but is clearly in need of further study. BACKGROUND In the 1990s, the mission risk of the reduction in force was mitigated through the planned increase of contractor support in theaters of operations.1 This time frame corresponded with the DOD/NATO mission in the Balkans. In addition, negotiations with NATO and the Balkan host nations resulted in Force Cap requirements.2 Force Caps limit the number of troops allowed to be deployed in theater. However, contractors are exempt from Force Cap requirements and thus the DOD will often deploy large numbers of contractors instead of troops in support, security, or other noncombat roles to fill mission requirements. A typical example might be if Country A allows the USA to deploy 10,000 soldiers within its borders, 4,000 of these soldiers may be needed to perform support functions, leaving only 6,000 slots for combat soldiers. However, if contractors are used instead to perform these support functions, the full 10,000 combat soldiers can be deployed in the area. This force-multiplier effect permits the combatant commander to have sufficient support in theater while strengthening the joint force’s fighting capability. The medical readiness of contractors entering theater is briefly discussed in the Joint Planning 4–10, Operational Combat Support document. It requires a predeployment medical and dental assessment in the 12-mo period before deployment to theater. However, criteria for deployability varies by theater and is largely left to the contractor and combatant commander’s joint force surgeon in coordination with subordinate joint force surgeons.3 Thus, the deployment requirements for contractors are less uniform and rigorous than for the uniformed soldiers. The US mission in Kosovo is fulfilled by using a combination of uniformed military personnel, DOD civilians, and contractors (US and local nationals). Over the course of the Kosovo Forces (KFOR) mission, improvements in safety and stability in Kosovo have led to the reduction in the overall size of the KFOR. The US medical footprint currently includes only a role 1 (troop medical clinic) medical capability on Camp Bondsteel. This capability consists of an emergency room physician and physician assistant providing triage, treatment for acute and chronic conditions, and when necessary evacuation to a higher level of care. The facility does not have a patient-holding capability. FINDINGS During our KFOR20 rotation, there were more contractors than soldiers in the Balkans in support of the Kosovo (NATO-KFOR) mission Joint Guardian. US contractors were authorized to receive medical care for acute and chronic medical issues and comprised approximately 26% of the total contract workforce with the remaining 74% made up of contracted local nationals. Acute medication needs were split between soldiers and contractors. However, chronic conditions were more prevalent in DOD contactors and thus the pharmacy needed to stock medications that were not typical of a medical role 1 operation (Table I). Specifically, DOD contractors required a wider variety of cardiovascular medications with increased prescription demand three times that of deployed soldiers. Contractors who were military retirees were eligible for pharmacy mail order benefit under the deployed prescription program. However, it fell to the pharmacist to guide and initiate and monitor this process. Also, deployed prescription program mailed medications can take 6 wk or more to arrive in theater and thus an interim supply must often be found. Further, contractor cases were often complicated by the fact that they were not followed by a primary care provider in theater and thus depended on the pharmacist to coordinate a provider visit to obtain prescriptions to continue their care. Table I. Kosovo Prescription Categories by Beneficiary Type Medication Category  Prescriptions (Contractors)  Prescription % (Contractors)  Prescription (Active Duty)  Prescription % (Active Duty)  Prescription Count Total  Prescription % (Total)  Antihistamine drugs  22  5  107  5  129  5.0  Anti-infective agents  36  8  179  8  215  8.3  Autonomic drugs  42  10  229  11  271  10.5  Blood formation, coagulation, and thrombosis  5  0  0  0  5  0.2  Cardiovascular drugs  52  12  86  4  138  5.3  Central nervous system agents  118  27  881  41  999  38.5  Devices  1  0  5  0  6  0.2  Diagnostic agents  2  0  0  0  2  0.1  Electrolytic, caloric, and water balance  22  5  15  1  37  1.4  Eye, ear, nose, and throat preps.  20  5  145  7  165  6.4  Gastrointestinal drugs  14  3  123  6  137  5.3  Hormones and synthetic substitutes  57  13  144  7  201  7.8  Miscellaneous therapeutic agents  5  1  32  1  37  1.4  Respiratory tract agents  14  3  54  3  68  2.6  Serums, toxoids, and vaccines  1  0  10  0  11  0.4  Skin and mucous membrane agents  28  6  138  6  166  6.4  Vitamins  1  0  6  0  7  0.3  Grand total  437    2157    2594    Medication Category  Prescriptions (Contractors)  Prescription % (Contractors)  Prescription (Active Duty)  Prescription % (Active Duty)  Prescription Count Total  Prescription % (Total)  Antihistamine drugs  22  5  107  5  129  5.0  Anti-infective agents  36  8  179  8  215  8.3  Autonomic drugs  42  10  229  11  271  10.5  Blood formation, coagulation, and thrombosis  5  0  0  0  5  0.2  Cardiovascular drugs  52  12  86  4  138  5.3  Central nervous system agents  118  27  881  41  999  38.5  Devices  1  0  5  0  6  0.2  Diagnostic agents  2  0  0  0  2  0.1  Electrolytic, caloric, and water balance  22  5  15  1  37  1.4  Eye, ear, nose, and throat preps.  20  5  145  7  165  6.4  Gastrointestinal drugs  14  3  123  6  137  5.3  Hormones and synthetic substitutes  57  13  144  7  201  7.8  Miscellaneous therapeutic agents  5  1  32  1  37  1.4  Respiratory tract agents  14  3  54  3  68  2.6  Serums, toxoids, and vaccines  1  0  10  0  11  0.4  Skin and mucous membrane agents  28  6  138  6  166  6.4  Vitamins  1  0  6  0  7  0.3  Grand total  437    2157    2594    Table I. Kosovo Prescription Categories by Beneficiary Type Medication Category  Prescriptions (Contractors)  Prescription % (Contractors)  Prescription (Active Duty)  Prescription % (Active Duty)  Prescription Count Total  Prescription % (Total)  Antihistamine drugs  22  5  107  5  129  5.0  Anti-infective agents  36  8  179  8  215  8.3  Autonomic drugs  42  10  229  11  271  10.5  Blood formation, coagulation, and thrombosis  5  0  0  0  5  0.2  Cardiovascular drugs  52  12  86  4  138  5.3  Central nervous system agents  118  27  881  41  999  38.5  Devices  1  0  5  0  6  0.2  Diagnostic agents  2  0  0  0  2  0.1  Electrolytic, caloric, and water balance  22  5  15  1  37  1.4  Eye, ear, nose, and throat preps.  20  5  145  7  165  6.4  Gastrointestinal drugs  14  3  123  6  137  5.3  Hormones and synthetic substitutes  57  13  144  7  201  7.8  Miscellaneous therapeutic agents  5  1  32  1  37  1.4  Respiratory tract agents  14  3  54  3  68  2.6  Serums, toxoids, and vaccines  1  0  10  0  11  0.4  Skin and mucous membrane agents  28  6  138  6  166  6.4  Vitamins  1  0  6  0  7  0.3  Grand total  437    2157    2594    Medication Category  Prescriptions (Contractors)  Prescription % (Contractors)  Prescription (Active Duty)  Prescription % (Active Duty)  Prescription Count Total  Prescription % (Total)  Antihistamine drugs  22  5  107  5  129  5.0  Anti-infective agents  36  8  179  8  215  8.3  Autonomic drugs  42  10  229  11  271  10.5  Blood formation, coagulation, and thrombosis  5  0  0  0  5  0.2  Cardiovascular drugs  52  12  86  4  138  5.3  Central nervous system agents  118  27  881  41  999  38.5  Devices  1  0  5  0  6  0.2  Diagnostic agents  2  0  0  0  2  0.1  Electrolytic, caloric, and water balance  22  5  15  1  37  1.4  Eye, ear, nose, and throat preps.  20  5  145  7  165  6.4  Gastrointestinal drugs  14  3  123  6  137  5.3  Hormones and synthetic substitutes  57  13  144  7  201  7.8  Miscellaneous therapeutic agents  5  1  32  1  37  1.4  Respiratory tract agents  14  3  54  3  68  2.6  Serums, toxoids, and vaccines  1  0  10  0  11  0.4  Skin and mucous membrane agents  28  6  138  6  166  6.4  Vitamins  1  0  6  0  7  0.3  Grand total  437    2157    2594    RESULTS The KFOR medical task force included a pharmacy providing role 1 level services consisting largely of sick call-related medications. The young active duty and reserve soldiers presented mainly for acute illness or injuries. The DOD contractors in many cases utilized the role 1 medical facility for routine chronic health care in addition to urgent/emergent needs. However, the contractors utilized the pharmacy services at a very different level. This was due to them arriving in theater on medications that then needed to be stocked and supplied routinely, which were not part of a role 1 mission. For instance, according to military deployment guidelines, blood thinners are a prohibited class of medications for soldiers deploying.4 However, we found the need to stock, dispense, and monitor these medications for certain contractors deployed in Kosovo. The physician assistant or medical doctor (90-d rotator) re-wrote the prescription and continued the care even though they were unable to follow the patient long term. This less than ideal situation was compounded as many of the US contractors in Kosovo are staying in theater several years and a few have been in theater over a decade. In many cases, mail order was an option, but largely it fell on the army pharmacist to determine contractor eligibility and sort through options to supply the contractor with medications. Recent cases noted during the KFOR (KFOR20) rotation: JF was a 65-yr-old White male contractor with hypertension, hypercholesterolemia, hypothyroidism, borderline diabetes mellitus, atrial fibrillation, and a 50-yr history of smoking cigarettes. He did not have a primary care provider in theater and got his care from the army physician assistant deployed in theater (who rotates every 9 mo). In January 2016, he was MedEvac’d by military Black Hawk to a neighboring nation’s civilian hospital with a left lower lobe infiltrate and spent a week as an inpatient with a community-acquired pneumonia. He returned briefly to theater; however, 2 wk later, his son died and he flew to the USA for the funeral. He returned to theater and presented to pharmacy for late refills on tiotropium, albuterol, levothyroxine, and nicotine patches and gum. He stated that he had begun smoking again due to stress and also revealed multiple vague somatic complaints for which he would like the pharmacist to address and make recommendations. DD was a 61 yr-old male contractor who has remained in theater except for biannual leave for the past 10 yr. He was a contractor with a desk job involving collating intelligence, security, and communication information. He first presented for medical care to our KFOR clinic in late 2015 with untreated hypertension and blood pressure consistently in the 160s/100s. He was referred and sent to a cardiologist in a neighboring nation and subsequently placed on lisinopril 10 mg, hydrochlorothiazide 25 mg (to be titrated to effect), and simvastatin 10 mg. Subsequent regimen was lisinopril 40 mg/hydrochlorothiazide 25 mg and blood pressure came within normal limits. He was counseled not to take decongestants for blood pressure concerns. After 10 d, he developed cold symptoms and began taking chlorpheniramine and dextromethorphan (Coricidin HBP), which he had purchased over the counter from the local exchange. After 3 d of starting Coricidin HBP, he presented to the medical clinic unable to void his bladder for the last 2 d. UA and gram stain showed no signs of infection. He was straight cath’ed and medically evacuated by ambulance to a neighboring nation for a urological consult. After 24 h, he was returned to theater with a diagnosis of benign prostatic hypertrophy and instructions for catheter to remain in place for 7 d. Pharmacy and medical logistics were consulted to find leg bags and supplies and an Rx for alfuzosin 10 mg. Within 24 hrs, he presented back to the medical clinic with generalized weakness, metal status changes, light headiness, and dark urine in his urine bag. Cipro 500 mg twice daily was started as urinary tract infection prophylaxis, but urinalysis and gram stain were negative for infection. At this visit, the pharmacist discovered the over-the-counter (exchange purchased) Coricidin HBP and recommended discontinuation because of possible anticholinergic effects on voiding, as well as holding the simvastatin until further notice for drug interaction or myopathy potential. As noted in Table II, we are not the first to uncover the discrepancy between the historic mission of army health care and the new requirement to provide care for retirees and other contractors in theater. In fact, when taken in total, it appears that a new class of beneficiary, herein referred to as deployed contractors, has been created. In recent years, this extension of care has been made common practice in the deployed environment. As has been borne out by other deployment’s after action reviews (Table II), this not only complicates the pharmacy and medical mission but also does not provide for the transition of contractor care as the mission winds down. Table II. Summary of Contractor Health Care Concerns Noted in Previous After Action Reviews Issue  Recommendations  Medical care to contractors prohibited except for life/limb/eyesight; contractors often had no alternative care options (as sending to Iraqi hospitals was often not an option), but government not reimbursed for care of these patients because of lack of staff/equipment to begin billing for the patients.  Develop policy-governing provision of medical care for contractors or mechanism to recoup costs for medical care provided; needs to be determined before deployment and may require additional military medical assets to help ensure proper care is provided and reimbursement occurs.6 *OIF 2010  DOD civilians/contractors were inappropriately deployed (Dental Class 3, uncontrolled diabetes, chronic pain patients) – adversely affects medical/dental assets that are allocated to treat active duty service members  Need additional personnel and funds to help provide care for DOD civilians/contractors7 *OIF 2010  Civilian contractors do not have access to a local civilian dentist and occupy 30%–40% of the workload in the military dental clinic – results in decreased dental care to soldiers  Contractors need their own civilian dentist to treat civilian support personnel *OIF 2010  KBR contractors, Iraqi contractors and citizens, and detainees comprised a large portion of our patient base and often presented with complex medical problems that required treatment with certain types of medications or equipment  It should become a standard for deploying units to stock Medical Equipment Sets with insulin, glucometers, antihypertensive, psych meds, etc. *OIF 2010  MNC-I OPORD sets forth general rules for care for contractors, but does not address eligibility for optometry and pharmacy services  This should be specifically addressed in the Rules for Care *OIF 2010  1–15% of medical treatment facility visits are related to contractor health care – most common conditions include diabetes, hypertension, and hyperlipidemia. Numerous contractors come into theater with CENTCOM deemed nondeployable conditions such as malignancy, anticoagulant therapy, CAD, and CHF  This places a burden on an already busy medical staff. *OIF 2010  There is no current process to capture maintenance medicines for contractors to ensure adequate supply of medications in stock and also brings into question certain personnel’s fitness to deploy based on some chronic medication therapy  Recommendation was to have a better screening process for maintenance med requirements during Soldier Readiness Process and maintain a database of current theater requirements based off of this. **OEF, Afghanistan 2010  Issue  Recommendations  Medical care to contractors prohibited except for life/limb/eyesight; contractors often had no alternative care options (as sending to Iraqi hospitals was often not an option), but government not reimbursed for care of these patients because of lack of staff/equipment to begin billing for the patients.  Develop policy-governing provision of medical care for contractors or mechanism to recoup costs for medical care provided; needs to be determined before deployment and may require additional military medical assets to help ensure proper care is provided and reimbursement occurs.6 *OIF 2010  DOD civilians/contractors were inappropriately deployed (Dental Class 3, uncontrolled diabetes, chronic pain patients) – adversely affects medical/dental assets that are allocated to treat active duty service members  Need additional personnel and funds to help provide care for DOD civilians/contractors7 *OIF 2010  Civilian contractors do not have access to a local civilian dentist and occupy 30%–40% of the workload in the military dental clinic – results in decreased dental care to soldiers  Contractors need their own civilian dentist to treat civilian support personnel *OIF 2010  KBR contractors, Iraqi contractors and citizens, and detainees comprised a large portion of our patient base and often presented with complex medical problems that required treatment with certain types of medications or equipment  It should become a standard for deploying units to stock Medical Equipment Sets with insulin, glucometers, antihypertensive, psych meds, etc. *OIF 2010  MNC-I OPORD sets forth general rules for care for contractors, but does not address eligibility for optometry and pharmacy services  This should be specifically addressed in the Rules for Care *OIF 2010  1–15% of medical treatment facility visits are related to contractor health care – most common conditions include diabetes, hypertension, and hyperlipidemia. Numerous contractors come into theater with CENTCOM deemed nondeployable conditions such as malignancy, anticoagulant therapy, CAD, and CHF  This places a burden on an already busy medical staff. *OIF 2010  There is no current process to capture maintenance medicines for contractors to ensure adequate supply of medications in stock and also brings into question certain personnel’s fitness to deploy based on some chronic medication therapy  Recommendation was to have a better screening process for maintenance med requirements during Soldier Readiness Process and maintain a database of current theater requirements based off of this. **OEF, Afghanistan 2010  *Operation Iraqi Freedom. **Operation Enduring Freedom. Table II. Summary of Contractor Health Care Concerns Noted in Previous After Action Reviews Issue  Recommendations  Medical care to contractors prohibited except for life/limb/eyesight; contractors often had no alternative care options (as sending to Iraqi hospitals was often not an option), but government not reimbursed for care of these patients because of lack of staff/equipment to begin billing for the patients.  Develop policy-governing provision of medical care for contractors or mechanism to recoup costs for medical care provided; needs to be determined before deployment and may require additional military medical assets to help ensure proper care is provided and reimbursement occurs.6 *OIF 2010  DOD civilians/contractors were inappropriately deployed (Dental Class 3, uncontrolled diabetes, chronic pain patients) – adversely affects medical/dental assets that are allocated to treat active duty service members  Need additional personnel and funds to help provide care for DOD civilians/contractors7 *OIF 2010  Civilian contractors do not have access to a local civilian dentist and occupy 30%–40% of the workload in the military dental clinic – results in decreased dental care to soldiers  Contractors need their own civilian dentist to treat civilian support personnel *OIF 2010  KBR contractors, Iraqi contractors and citizens, and detainees comprised a large portion of our patient base and often presented with complex medical problems that required treatment with certain types of medications or equipment  It should become a standard for deploying units to stock Medical Equipment Sets with insulin, glucometers, antihypertensive, psych meds, etc. *OIF 2010  MNC-I OPORD sets forth general rules for care for contractors, but does not address eligibility for optometry and pharmacy services  This should be specifically addressed in the Rules for Care *OIF 2010  1–15% of medical treatment facility visits are related to contractor health care – most common conditions include diabetes, hypertension, and hyperlipidemia. Numerous contractors come into theater with CENTCOM deemed nondeployable conditions such as malignancy, anticoagulant therapy, CAD, and CHF  This places a burden on an already busy medical staff. *OIF 2010  There is no current process to capture maintenance medicines for contractors to ensure adequate supply of medications in stock and also brings into question certain personnel’s fitness to deploy based on some chronic medication therapy  Recommendation was to have a better screening process for maintenance med requirements during Soldier Readiness Process and maintain a database of current theater requirements based off of this. **OEF, Afghanistan 2010  Issue  Recommendations  Medical care to contractors prohibited except for life/limb/eyesight; contractors often had no alternative care options (as sending to Iraqi hospitals was often not an option), but government not reimbursed for care of these patients because of lack of staff/equipment to begin billing for the patients.  Develop policy-governing provision of medical care for contractors or mechanism to recoup costs for medical care provided; needs to be determined before deployment and may require additional military medical assets to help ensure proper care is provided and reimbursement occurs.6 *OIF 2010  DOD civilians/contractors were inappropriately deployed (Dental Class 3, uncontrolled diabetes, chronic pain patients) – adversely affects medical/dental assets that are allocated to treat active duty service members  Need additional personnel and funds to help provide care for DOD civilians/contractors7 *OIF 2010  Civilian contractors do not have access to a local civilian dentist and occupy 30%–40% of the workload in the military dental clinic – results in decreased dental care to soldiers  Contractors need their own civilian dentist to treat civilian support personnel *OIF 2010  KBR contractors, Iraqi contractors and citizens, and detainees comprised a large portion of our patient base and often presented with complex medical problems that required treatment with certain types of medications or equipment  It should become a standard for deploying units to stock Medical Equipment Sets with insulin, glucometers, antihypertensive, psych meds, etc. *OIF 2010  MNC-I OPORD sets forth general rules for care for contractors, but does not address eligibility for optometry and pharmacy services  This should be specifically addressed in the Rules for Care *OIF 2010  1–15% of medical treatment facility visits are related to contractor health care – most common conditions include diabetes, hypertension, and hyperlipidemia. Numerous contractors come into theater with CENTCOM deemed nondeployable conditions such as malignancy, anticoagulant therapy, CAD, and CHF  This places a burden on an already busy medical staff. *OIF 2010  There is no current process to capture maintenance medicines for contractors to ensure adequate supply of medications in stock and also brings into question certain personnel’s fitness to deploy based on some chronic medication therapy  Recommendation was to have a better screening process for maintenance med requirements during Soldier Readiness Process and maintain a database of current theater requirements based off of this. **OEF, Afghanistan 2010  *Operation Iraqi Freedom. **Operation Enduring Freedom. Table III provides composite health care system (CHCS) appointment data from the Camp Bondsteel Clinic from March 2015 through February 2016. Medical appointments for deployed US contractors comprised 12% of all medical visits. Medical information to assess patient acuity other than prescription data was not available for analysis. At the present time, U.S. Army Europe medical planners do not consider contract requirements when determining the medical footprint for Kosovo.5 Two factors are attributed to the decision to exclude the medical requirements of deployed contractors. First, medical support requirements for this patient population is thought to be negligible and within the capabilities of the existing footprint. Second, the Soldier Readiness Process screens out contractors with chronic medical conditions not conducive for a deployed environment with exceptions only possible through a waiver process. However, it is clear from our review of prescription data that logistical and care coordination grows increasingly complex as US Forces assume chronic care responsibilities for DOD contractors. Table III. Kosovo Quarterly Patient Appointment Data, March 15–February 16 Patient Detail  Appointment Status  March to May 15  June to August 15  September to November 15  December 15 to February 16  Total  Active duty  Sick call  58  111  87  40  296  Phone consult  10  3  2  3  18  Walk in  372  420  751  511  2054  Active duty dependent  Sick call  2  1  3  1  7  Phone consult  0  0  0  0  0  Walk in  1  2  7  8  18  Contractor  Sick call  11  11  21  4  47  Phone consult  0  1  0  1  2  Walk in  54  42  47  46  189  Retired  Sick call  2  7  4  1  14  Phone consult  0  0  2  2  4  Walk in  15  15  19  17  66    Total  525  613  943  634  2715    % Contractor + retired  16  12  10  11  12  Patient Detail  Appointment Status  March to May 15  June to August 15  September to November 15  December 15 to February 16  Total  Active duty  Sick call  58  111  87  40  296  Phone consult  10  3  2  3  18  Walk in  372  420  751  511  2054  Active duty dependent  Sick call  2  1  3  1  7  Phone consult  0  0  0  0  0  Walk in  1  2  7  8  18  Contractor  Sick call  11  11  21  4  47  Phone consult  0  1  0  1  2  Walk in  54  42  47  46  189  Retired  Sick call  2  7  4  1  14  Phone consult  0  0  2  2  4  Walk in  15  15  19  17  66    Total  525  613  943  634  2715    % Contractor + retired  16  12  10  11  12  Table III. Kosovo Quarterly Patient Appointment Data, March 15–February 16 Patient Detail  Appointment Status  March to May 15  June to August 15  September to November 15  December 15 to February 16  Total  Active duty  Sick call  58  111  87  40  296  Phone consult  10  3  2  3  18  Walk in  372  420  751  511  2054  Active duty dependent  Sick call  2  1  3  1  7  Phone consult  0  0  0  0  0  Walk in  1  2  7  8  18  Contractor  Sick call  11  11  21  4  47  Phone consult  0  1  0  1  2  Walk in  54  42  47  46  189  Retired  Sick call  2  7  4  1  14  Phone consult  0  0  2  2  4  Walk in  15  15  19  17  66    Total  525  613  943  634  2715    % Contractor + retired  16  12  10  11  12  Patient Detail  Appointment Status  March to May 15  June to August 15  September to November 15  December 15 to February 16  Total  Active duty  Sick call  58  111  87  40  296  Phone consult  10  3  2  3  18  Walk in  372  420  751  511  2054  Active duty dependent  Sick call  2  1  3  1  7  Phone consult  0  0  0  0  0  Walk in  1  2  7  8  18  Contractor  Sick call  11  11  21  4  47  Phone consult  0  1  0  1  2  Walk in  54  42  47  46  189  Retired  Sick call  2  7  4  1  14  Phone consult  0  0  2  2  4  Walk in  15  15  19  17  66    Total  525  613  943  634  2715    % Contractor + retired  16  12  10  11  12  Table IV shows the overall CHCS breakdown of prescription volume by patient category from the Camp Bondsteel Kosovo Pharmacy from March 2015 to February 2016. Our data show that 16% of the prescriptions are attributable to the contractors. However, as in the cases noted above, the quantity of prescriptions does not represent the whole story as the acuity of the illness is typically higher among contractor visits versus active duty. Further, even caring for retirees is not historically a typical mission for deployed medical assets operating at a role 1 level. Table IV. Kosovo Prescription Volume and Percentage Kosovo Prescription Data (March 15–February 16)        Total Rx  %  Active duty  2157  83  Active duty dependents  22  1  Retired  139  5  Other  298  11  Total  2616    Kosovo Prescription Data (March 15–February 16)        Total Rx  %  Active duty  2157  83  Active duty dependents  22  1  Retired  139  5  Other  298  11  Total  2616    Note: Active duty dependent’s Rx’s were likely coded in CHCS incorrectly. The retired and other categories represent Rx’s for DOD contractors. Table IV. Kosovo Prescription Volume and Percentage Kosovo Prescription Data (March 15–February 16)        Total Rx  %  Active duty  2157  83  Active duty dependents  22  1  Retired  139  5  Other  298  11  Total  2616    Kosovo Prescription Data (March 15–February 16)        Total Rx  %  Active duty  2157  83  Active duty dependents  22  1  Retired  139  5  Other  298  11  Total  2616    Note: Active duty dependent’s Rx’s were likely coded in CHCS incorrectly. The retired and other categories represent Rx’s for DOD contractors. Medical Commander Perspective The pharmacy was a very visible area that was affected by the contractor population, but it is part of a larger set of stressors on the limited medical assets that may also be worthy of further exploration. As noted in the findings section of this paper, contractors often do not consult with a primary care provider in coordinating their medications; we have also noted cases where they may wait for a provider to “rotate out” and potentially find a replacement who may be more favorable to their requests for certain treatment regimens. There are currently seven different contractors employing US personnel on Camp Bondsteel. Depending on the terms of their contract, different sets of the population have different rules for eligibility and reimbursement of medical treatment. In addition, some contractor employees are retired military personnel (making them eligible for full medical benefits above other employees of the same company), and some of the contractors employ local national personnel (who are eligible for emergency care in cases of life, limb, or eyesight only). The task force’s pharmacy and patient administration sections, who also rotate every 9 mo, must remain vigilant to ensure that contractor encounters are properly coded and that additional costs of treating this population including high-cost medications is captured and recouped by the army. Discussion With the 2015 Joint Chiefs of Staff projections of reduction in end strength of the Active Component, the National Guard and Army Reserve, it seems likely that the reliance on contractor support will continue at or near current levels. In fact, Pentagon predictions are that with the current drawdown, requirements, at least for security contractors, will increase significantly.6 With contractors already representing greater than 50% of the deployed DOD force, leaders, planners, and contract reviewers must consider the legal and logistical impact on pharmacy operations in theater. As contractor dependence is not likely to decrease, solutions such as carve outs or strategies for off-ramping contractor pharmaceutical care need to be considered. It is our experience that DOD contractors will seek military care regardless of contract stipulations. Mission planners instead may want to include contract medical care requirements as part of medical planning efforts. Such actions should include capability to provide chronic care management and associated medications. Further, considerations for the retrograding and termination of pharmacy services need the attention of medical planners when diminishing a medical footprint. Finally, as the army continues to employ large numbers of contractors in war zones, the American public is being introduced to this topic in the media. In the Frontline documentary Private Warriors, Peter Singer documents the increased reliance on contractor support and the cost implications.7 Although pharmacy services and costs are not specifically addressed in this documentary or the media as of yet, it is likely a future topic given the high costs and seemingly divergent mission of army pharmacy to support these contractors. It is tempting to think that army leaders can continue to make contractor decisions in a vacuum, without consideration of the impact on medical support requirements. However, this is probably not a valid assumption. The quandary is that army pharmacy is saddled with complicated automation and inventory to support these contractors. Furthermore, as the DOD mission winds down, the pharmacy mission could inversely rise as it is likely that contractors will remain in the theaters of operations, at least in the near term. Limitations One of the limitations of the current review is that CHCS does not account for the deployed prescription program Rx’s for contractors that were moved to mail order during deployment. Also, other sources of prescriptions, such as the Veterans Affairs mail order program, are not accounted for. We estimate that at least half of the contractor Rx’s for chronic medications were obtained outside of the CHCS system. Contractor Rx data are thus likely underrepresented. Conclusion We found that contractors were serving in the Balkan theater at a greater than 1:1 ratio of contractors to soldiers. In most cases, contractors were eligible for medical and pharmacy care from our deployed assets. Contractors in Kosovo were typically older than deployed soldiers and thus their pharmaceutical needs were more complex. This complicated our pharmacy operation, which on the one hand was trying to retrograde as the mission wound down, yet, on the other hand, had to expand to a more complex medication footprint to support the DOD contractors in theater. Acknowledgments The authors would like to acknowledge Mr. Kevin Book, MBA, Program Analysis and Evaluation Division, USAMEDCOM, and LTC Johnny Ray, APA-C, Clinical Operations, U.S. Army Europe, for their assistance in the preparation and review of this article. References 1 Schwartz M: Department of Defense’s use of Contractors to support Military Operations: Background, Analysis and Issues for Congress: 1(1). Available at https://www.fas.org/sgp/crs/natsec/R43074.pdf; accessed December 22, 2016. 2 Hammes TX: Private Contractors in Conflict Zones, the Good, the Bad, and the Strategic Impact, Strategy Forum – National Defense University: 1(1). Available at http://psm.du.edu/media/documents/reports_and_stats/think_tanks/inss_hammes-private-contractors.pdf; accessed December 22, 2016. 3 Operational Contract Support. Joint Publication 4–10. V-1(1): July 2014. Available at http://www.dtic.mil/doctrine/new_pubs/jp4_10.pdf; accessed December 22, 2016. 4 USCENTCOM, MOD-12 Individual Protection and Individual-Unit Deployment Policy, 15.C.1.E. Available at http://www.public.navy.mil/ia/dha/Documents/USCENTCOM_MOD_TWELVE.pdf; accessed July 7, 2017. 5 Mulally KJ (Exec Dir Office of Command Surgeon General): “Re: Kosovo RFI from Pharm” Message to John Spain. September 20, 2016. 6 Contractor Support of US Operations in the USCENTCOM Area of Responsibility: Pentagon Report to Congress January 2016. Available at http://www.acq.osd.mil/log/PS/.CENTCOM_reports.html/5A_January_2016_Final.pdf; accessed December 24, 2016. 7 PBS-Frontline Documentaries Video: Private Warriors. Available at https://www.youtube.com/watch?v=WSUnFPVjVpg; accessed May 2, 2017. Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Considerations for Retrograding Deployed Army Pharmacy Operations: What about Department of Defense Civilian Contractors? Lessons from Kosovo

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Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.
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Abstract

Abstract Background Over the past two decades, changes in mission and expectations of deployed medical assets are requiring adaptations of pharmacy services. Specifically, the Department of Defense (DOD)-deployed contractors in theater are now eligible for varying levels of care from DOD-deployed assets. Pharmacy must now stock and maintain a complex medication footprint. This new requirement makes the attempt to retrograde a long established deployed pharmacy difficult and presents new challenges. Methods We review the issues surrounding this quandary from the perspective of the deployed pharmacy in Kosovo, one of the longest standing theaters of deployed medical assets. Findings Data from the 20th and 21st medical rotations in this theater demonstrate that DOD contractors consume a significant portion of pharmacy operational support. However, not only do contractors increase the volume but also pharmacy must address the use and monitoring of complex medications such as anticoagulants, antidiabetics, sleep, and psychiatric medications, as well as chronic obstructive pulmonary disease and asthma drugs, which are not typical in the deployed environment. Discussion/Impact/Recommendations Contractors are now serving in the Balkan theater at a greater than 1:1 ratio of contractors to soldiers. Contractors are typically older than deployed soldiers and thus their pharmaceutical needs are more complex. This complicates the pharmacy operation, which on the one hand is trying to retrograde as the mission winds down, yet, on the other hand, must expand to more complex operations to support the DOD contractors in theater. INTRODUCTION Army pharmacy is proficient at deploying to theater as well as starting and maintaining pharmacy operations to meet the initial and sustained mission requirements. However, published literature is limited regarding how pharmacy services terminate as the overall Department of Defense (DOD) mission winds down. Newer considerations such as DOD contractor support and the management of their health care has been less studied. We look at the example from the pharmacy in Kosovo, which has been deployed in the Balkan theater of operations for nearly 20 yr. Contractors there and elsewhere are often dependent on DOD pharmacy for their prescription needs, and nowhere has this become more evident than in Kosovo. Force management issues such as Force Caps have necessitated a greater than 1:1 ratio of contractors to soldiers in the Balkans theater, thereby complicating the mission of the pharmacy. Initially, the thought was that the DOD contractors arriving from the USA would do similar jobs as soldiers in theater and have similar pharmaceutical needs. Thus, their contracts often stipulate such a provision. However, it has become apparent that contractors from the USA are often older and many are in their sixth or seventh decade of life and more in need of a full service pharmacy than the typical deployed soldier. Further, the Soldier Readiness Process, a requirement for all deploying, appears less rigorous for DOD contractors than for soldiers. Contractors arrive and remain in theater with multiple comorbidities that are not consistent with available care to manage their chronic conditions. This conundrum is explored briefly, but is clearly in need of further study. BACKGROUND In the 1990s, the mission risk of the reduction in force was mitigated through the planned increase of contractor support in theaters of operations.1 This time frame corresponded with the DOD/NATO mission in the Balkans. In addition, negotiations with NATO and the Balkan host nations resulted in Force Cap requirements.2 Force Caps limit the number of troops allowed to be deployed in theater. However, contractors are exempt from Force Cap requirements and thus the DOD will often deploy large numbers of contractors instead of troops in support, security, or other noncombat roles to fill mission requirements. A typical example might be if Country A allows the USA to deploy 10,000 soldiers within its borders, 4,000 of these soldiers may be needed to perform support functions, leaving only 6,000 slots for combat soldiers. However, if contractors are used instead to perform these support functions, the full 10,000 combat soldiers can be deployed in the area. This force-multiplier effect permits the combatant commander to have sufficient support in theater while strengthening the joint force’s fighting capability. The medical readiness of contractors entering theater is briefly discussed in the Joint Planning 4–10, Operational Combat Support document. It requires a predeployment medical and dental assessment in the 12-mo period before deployment to theater. However, criteria for deployability varies by theater and is largely left to the contractor and combatant commander’s joint force surgeon in coordination with subordinate joint force surgeons.3 Thus, the deployment requirements for contractors are less uniform and rigorous than for the uniformed soldiers. The US mission in Kosovo is fulfilled by using a combination of uniformed military personnel, DOD civilians, and contractors (US and local nationals). Over the course of the Kosovo Forces (KFOR) mission, improvements in safety and stability in Kosovo have led to the reduction in the overall size of the KFOR. The US medical footprint currently includes only a role 1 (troop medical clinic) medical capability on Camp Bondsteel. This capability consists of an emergency room physician and physician assistant providing triage, treatment for acute and chronic conditions, and when necessary evacuation to a higher level of care. The facility does not have a patient-holding capability. FINDINGS During our KFOR20 rotation, there were more contractors than soldiers in the Balkans in support of the Kosovo (NATO-KFOR) mission Joint Guardian. US contractors were authorized to receive medical care for acute and chronic medical issues and comprised approximately 26% of the total contract workforce with the remaining 74% made up of contracted local nationals. Acute medication needs were split between soldiers and contractors. However, chronic conditions were more prevalent in DOD contactors and thus the pharmacy needed to stock medications that were not typical of a medical role 1 operation (Table I). Specifically, DOD contractors required a wider variety of cardiovascular medications with increased prescription demand three times that of deployed soldiers. Contractors who were military retirees were eligible for pharmacy mail order benefit under the deployed prescription program. However, it fell to the pharmacist to guide and initiate and monitor this process. Also, deployed prescription program mailed medications can take 6 wk or more to arrive in theater and thus an interim supply must often be found. Further, contractor cases were often complicated by the fact that they were not followed by a primary care provider in theater and thus depended on the pharmacist to coordinate a provider visit to obtain prescriptions to continue their care. Table I. Kosovo Prescription Categories by Beneficiary Type Medication Category  Prescriptions (Contractors)  Prescription % (Contractors)  Prescription (Active Duty)  Prescription % (Active Duty)  Prescription Count Total  Prescription % (Total)  Antihistamine drugs  22  5  107  5  129  5.0  Anti-infective agents  36  8  179  8  215  8.3  Autonomic drugs  42  10  229  11  271  10.5  Blood formation, coagulation, and thrombosis  5  0  0  0  5  0.2  Cardiovascular drugs  52  12  86  4  138  5.3  Central nervous system agents  118  27  881  41  999  38.5  Devices  1  0  5  0  6  0.2  Diagnostic agents  2  0  0  0  2  0.1  Electrolytic, caloric, and water balance  22  5  15  1  37  1.4  Eye, ear, nose, and throat preps.  20  5  145  7  165  6.4  Gastrointestinal drugs  14  3  123  6  137  5.3  Hormones and synthetic substitutes  57  13  144  7  201  7.8  Miscellaneous therapeutic agents  5  1  32  1  37  1.4  Respiratory tract agents  14  3  54  3  68  2.6  Serums, toxoids, and vaccines  1  0  10  0  11  0.4  Skin and mucous membrane agents  28  6  138  6  166  6.4  Vitamins  1  0  6  0  7  0.3  Grand total  437    2157    2594    Medication Category  Prescriptions (Contractors)  Prescription % (Contractors)  Prescription (Active Duty)  Prescription % (Active Duty)  Prescription Count Total  Prescription % (Total)  Antihistamine drugs  22  5  107  5  129  5.0  Anti-infective agents  36  8  179  8  215  8.3  Autonomic drugs  42  10  229  11  271  10.5  Blood formation, coagulation, and thrombosis  5  0  0  0  5  0.2  Cardiovascular drugs  52  12  86  4  138  5.3  Central nervous system agents  118  27  881  41  999  38.5  Devices  1  0  5  0  6  0.2  Diagnostic agents  2  0  0  0  2  0.1  Electrolytic, caloric, and water balance  22  5  15  1  37  1.4  Eye, ear, nose, and throat preps.  20  5  145  7  165  6.4  Gastrointestinal drugs  14  3  123  6  137  5.3  Hormones and synthetic substitutes  57  13  144  7  201  7.8  Miscellaneous therapeutic agents  5  1  32  1  37  1.4  Respiratory tract agents  14  3  54  3  68  2.6  Serums, toxoids, and vaccines  1  0  10  0  11  0.4  Skin and mucous membrane agents  28  6  138  6  166  6.4  Vitamins  1  0  6  0  7  0.3  Grand total  437    2157    2594    Table I. Kosovo Prescription Categories by Beneficiary Type Medication Category  Prescriptions (Contractors)  Prescription % (Contractors)  Prescription (Active Duty)  Prescription % (Active Duty)  Prescription Count Total  Prescription % (Total)  Antihistamine drugs  22  5  107  5  129  5.0  Anti-infective agents  36  8  179  8  215  8.3  Autonomic drugs  42  10  229  11  271  10.5  Blood formation, coagulation, and thrombosis  5  0  0  0  5  0.2  Cardiovascular drugs  52  12  86  4  138  5.3  Central nervous system agents  118  27  881  41  999  38.5  Devices  1  0  5  0  6  0.2  Diagnostic agents  2  0  0  0  2  0.1  Electrolytic, caloric, and water balance  22  5  15  1  37  1.4  Eye, ear, nose, and throat preps.  20  5  145  7  165  6.4  Gastrointestinal drugs  14  3  123  6  137  5.3  Hormones and synthetic substitutes  57  13  144  7  201  7.8  Miscellaneous therapeutic agents  5  1  32  1  37  1.4  Respiratory tract agents  14  3  54  3  68  2.6  Serums, toxoids, and vaccines  1  0  10  0  11  0.4  Skin and mucous membrane agents  28  6  138  6  166  6.4  Vitamins  1  0  6  0  7  0.3  Grand total  437    2157    2594    Medication Category  Prescriptions (Contractors)  Prescription % (Contractors)  Prescription (Active Duty)  Prescription % (Active Duty)  Prescription Count Total  Prescription % (Total)  Antihistamine drugs  22  5  107  5  129  5.0  Anti-infective agents  36  8  179  8  215  8.3  Autonomic drugs  42  10  229  11  271  10.5  Blood formation, coagulation, and thrombosis  5  0  0  0  5  0.2  Cardiovascular drugs  52  12  86  4  138  5.3  Central nervous system agents  118  27  881  41  999  38.5  Devices  1  0  5  0  6  0.2  Diagnostic agents  2  0  0  0  2  0.1  Electrolytic, caloric, and water balance  22  5  15  1  37  1.4  Eye, ear, nose, and throat preps.  20  5  145  7  165  6.4  Gastrointestinal drugs  14  3  123  6  137  5.3  Hormones and synthetic substitutes  57  13  144  7  201  7.8  Miscellaneous therapeutic agents  5  1  32  1  37  1.4  Respiratory tract agents  14  3  54  3  68  2.6  Serums, toxoids, and vaccines  1  0  10  0  11  0.4  Skin and mucous membrane agents  28  6  138  6  166  6.4  Vitamins  1  0  6  0  7  0.3  Grand total  437    2157    2594    RESULTS The KFOR medical task force included a pharmacy providing role 1 level services consisting largely of sick call-related medications. The young active duty and reserve soldiers presented mainly for acute illness or injuries. The DOD contractors in many cases utilized the role 1 medical facility for routine chronic health care in addition to urgent/emergent needs. However, the contractors utilized the pharmacy services at a very different level. This was due to them arriving in theater on medications that then needed to be stocked and supplied routinely, which were not part of a role 1 mission. For instance, according to military deployment guidelines, blood thinners are a prohibited class of medications for soldiers deploying.4 However, we found the need to stock, dispense, and monitor these medications for certain contractors deployed in Kosovo. The physician assistant or medical doctor (90-d rotator) re-wrote the prescription and continued the care even though they were unable to follow the patient long term. This less than ideal situation was compounded as many of the US contractors in Kosovo are staying in theater several years and a few have been in theater over a decade. In many cases, mail order was an option, but largely it fell on the army pharmacist to determine contractor eligibility and sort through options to supply the contractor with medications. Recent cases noted during the KFOR (KFOR20) rotation: JF was a 65-yr-old White male contractor with hypertension, hypercholesterolemia, hypothyroidism, borderline diabetes mellitus, atrial fibrillation, and a 50-yr history of smoking cigarettes. He did not have a primary care provider in theater and got his care from the army physician assistant deployed in theater (who rotates every 9 mo). In January 2016, he was MedEvac’d by military Black Hawk to a neighboring nation’s civilian hospital with a left lower lobe infiltrate and spent a week as an inpatient with a community-acquired pneumonia. He returned briefly to theater; however, 2 wk later, his son died and he flew to the USA for the funeral. He returned to theater and presented to pharmacy for late refills on tiotropium, albuterol, levothyroxine, and nicotine patches and gum. He stated that he had begun smoking again due to stress and also revealed multiple vague somatic complaints for which he would like the pharmacist to address and make recommendations. DD was a 61 yr-old male contractor who has remained in theater except for biannual leave for the past 10 yr. He was a contractor with a desk job involving collating intelligence, security, and communication information. He first presented for medical care to our KFOR clinic in late 2015 with untreated hypertension and blood pressure consistently in the 160s/100s. He was referred and sent to a cardiologist in a neighboring nation and subsequently placed on lisinopril 10 mg, hydrochlorothiazide 25 mg (to be titrated to effect), and simvastatin 10 mg. Subsequent regimen was lisinopril 40 mg/hydrochlorothiazide 25 mg and blood pressure came within normal limits. He was counseled not to take decongestants for blood pressure concerns. After 10 d, he developed cold symptoms and began taking chlorpheniramine and dextromethorphan (Coricidin HBP), which he had purchased over the counter from the local exchange. After 3 d of starting Coricidin HBP, he presented to the medical clinic unable to void his bladder for the last 2 d. UA and gram stain showed no signs of infection. He was straight cath’ed and medically evacuated by ambulance to a neighboring nation for a urological consult. After 24 h, he was returned to theater with a diagnosis of benign prostatic hypertrophy and instructions for catheter to remain in place for 7 d. Pharmacy and medical logistics were consulted to find leg bags and supplies and an Rx for alfuzosin 10 mg. Within 24 hrs, he presented back to the medical clinic with generalized weakness, metal status changes, light headiness, and dark urine in his urine bag. Cipro 500 mg twice daily was started as urinary tract infection prophylaxis, but urinalysis and gram stain were negative for infection. At this visit, the pharmacist discovered the over-the-counter (exchange purchased) Coricidin HBP and recommended discontinuation because of possible anticholinergic effects on voiding, as well as holding the simvastatin until further notice for drug interaction or myopathy potential. As noted in Table II, we are not the first to uncover the discrepancy between the historic mission of army health care and the new requirement to provide care for retirees and other contractors in theater. In fact, when taken in total, it appears that a new class of beneficiary, herein referred to as deployed contractors, has been created. In recent years, this extension of care has been made common practice in the deployed environment. As has been borne out by other deployment’s after action reviews (Table II), this not only complicates the pharmacy and medical mission but also does not provide for the transition of contractor care as the mission winds down. Table II. Summary of Contractor Health Care Concerns Noted in Previous After Action Reviews Issue  Recommendations  Medical care to contractors prohibited except for life/limb/eyesight; contractors often had no alternative care options (as sending to Iraqi hospitals was often not an option), but government not reimbursed for care of these patients because of lack of staff/equipment to begin billing for the patients.  Develop policy-governing provision of medical care for contractors or mechanism to recoup costs for medical care provided; needs to be determined before deployment and may require additional military medical assets to help ensure proper care is provided and reimbursement occurs.6 *OIF 2010  DOD civilians/contractors were inappropriately deployed (Dental Class 3, uncontrolled diabetes, chronic pain patients) – adversely affects medical/dental assets that are allocated to treat active duty service members  Need additional personnel and funds to help provide care for DOD civilians/contractors7 *OIF 2010  Civilian contractors do not have access to a local civilian dentist and occupy 30%–40% of the workload in the military dental clinic – results in decreased dental care to soldiers  Contractors need their own civilian dentist to treat civilian support personnel *OIF 2010  KBR contractors, Iraqi contractors and citizens, and detainees comprised a large portion of our patient base and often presented with complex medical problems that required treatment with certain types of medications or equipment  It should become a standard for deploying units to stock Medical Equipment Sets with insulin, glucometers, antihypertensive, psych meds, etc. *OIF 2010  MNC-I OPORD sets forth general rules for care for contractors, but does not address eligibility for optometry and pharmacy services  This should be specifically addressed in the Rules for Care *OIF 2010  1–15% of medical treatment facility visits are related to contractor health care – most common conditions include diabetes, hypertension, and hyperlipidemia. Numerous contractors come into theater with CENTCOM deemed nondeployable conditions such as malignancy, anticoagulant therapy, CAD, and CHF  This places a burden on an already busy medical staff. *OIF 2010  There is no current process to capture maintenance medicines for contractors to ensure adequate supply of medications in stock and also brings into question certain personnel’s fitness to deploy based on some chronic medication therapy  Recommendation was to have a better screening process for maintenance med requirements during Soldier Readiness Process and maintain a database of current theater requirements based off of this. **OEF, Afghanistan 2010  Issue  Recommendations  Medical care to contractors prohibited except for life/limb/eyesight; contractors often had no alternative care options (as sending to Iraqi hospitals was often not an option), but government not reimbursed for care of these patients because of lack of staff/equipment to begin billing for the patients.  Develop policy-governing provision of medical care for contractors or mechanism to recoup costs for medical care provided; needs to be determined before deployment and may require additional military medical assets to help ensure proper care is provided and reimbursement occurs.6 *OIF 2010  DOD civilians/contractors were inappropriately deployed (Dental Class 3, uncontrolled diabetes, chronic pain patients) – adversely affects medical/dental assets that are allocated to treat active duty service members  Need additional personnel and funds to help provide care for DOD civilians/contractors7 *OIF 2010  Civilian contractors do not have access to a local civilian dentist and occupy 30%–40% of the workload in the military dental clinic – results in decreased dental care to soldiers  Contractors need their own civilian dentist to treat civilian support personnel *OIF 2010  KBR contractors, Iraqi contractors and citizens, and detainees comprised a large portion of our patient base and often presented with complex medical problems that required treatment with certain types of medications or equipment  It should become a standard for deploying units to stock Medical Equipment Sets with insulin, glucometers, antihypertensive, psych meds, etc. *OIF 2010  MNC-I OPORD sets forth general rules for care for contractors, but does not address eligibility for optometry and pharmacy services  This should be specifically addressed in the Rules for Care *OIF 2010  1–15% of medical treatment facility visits are related to contractor health care – most common conditions include diabetes, hypertension, and hyperlipidemia. Numerous contractors come into theater with CENTCOM deemed nondeployable conditions such as malignancy, anticoagulant therapy, CAD, and CHF  This places a burden on an already busy medical staff. *OIF 2010  There is no current process to capture maintenance medicines for contractors to ensure adequate supply of medications in stock and also brings into question certain personnel’s fitness to deploy based on some chronic medication therapy  Recommendation was to have a better screening process for maintenance med requirements during Soldier Readiness Process and maintain a database of current theater requirements based off of this. **OEF, Afghanistan 2010  *Operation Iraqi Freedom. **Operation Enduring Freedom. Table II. Summary of Contractor Health Care Concerns Noted in Previous After Action Reviews Issue  Recommendations  Medical care to contractors prohibited except for life/limb/eyesight; contractors often had no alternative care options (as sending to Iraqi hospitals was often not an option), but government not reimbursed for care of these patients because of lack of staff/equipment to begin billing for the patients.  Develop policy-governing provision of medical care for contractors or mechanism to recoup costs for medical care provided; needs to be determined before deployment and may require additional military medical assets to help ensure proper care is provided and reimbursement occurs.6 *OIF 2010  DOD civilians/contractors were inappropriately deployed (Dental Class 3, uncontrolled diabetes, chronic pain patients) – adversely affects medical/dental assets that are allocated to treat active duty service members  Need additional personnel and funds to help provide care for DOD civilians/contractors7 *OIF 2010  Civilian contractors do not have access to a local civilian dentist and occupy 30%–40% of the workload in the military dental clinic – results in decreased dental care to soldiers  Contractors need their own civilian dentist to treat civilian support personnel *OIF 2010  KBR contractors, Iraqi contractors and citizens, and detainees comprised a large portion of our patient base and often presented with complex medical problems that required treatment with certain types of medications or equipment  It should become a standard for deploying units to stock Medical Equipment Sets with insulin, glucometers, antihypertensive, psych meds, etc. *OIF 2010  MNC-I OPORD sets forth general rules for care for contractors, but does not address eligibility for optometry and pharmacy services  This should be specifically addressed in the Rules for Care *OIF 2010  1–15% of medical treatment facility visits are related to contractor health care – most common conditions include diabetes, hypertension, and hyperlipidemia. Numerous contractors come into theater with CENTCOM deemed nondeployable conditions such as malignancy, anticoagulant therapy, CAD, and CHF  This places a burden on an already busy medical staff. *OIF 2010  There is no current process to capture maintenance medicines for contractors to ensure adequate supply of medications in stock and also brings into question certain personnel’s fitness to deploy based on some chronic medication therapy  Recommendation was to have a better screening process for maintenance med requirements during Soldier Readiness Process and maintain a database of current theater requirements based off of this. **OEF, Afghanistan 2010  Issue  Recommendations  Medical care to contractors prohibited except for life/limb/eyesight; contractors often had no alternative care options (as sending to Iraqi hospitals was often not an option), but government not reimbursed for care of these patients because of lack of staff/equipment to begin billing for the patients.  Develop policy-governing provision of medical care for contractors or mechanism to recoup costs for medical care provided; needs to be determined before deployment and may require additional military medical assets to help ensure proper care is provided and reimbursement occurs.6 *OIF 2010  DOD civilians/contractors were inappropriately deployed (Dental Class 3, uncontrolled diabetes, chronic pain patients) – adversely affects medical/dental assets that are allocated to treat active duty service members  Need additional personnel and funds to help provide care for DOD civilians/contractors7 *OIF 2010  Civilian contractors do not have access to a local civilian dentist and occupy 30%–40% of the workload in the military dental clinic – results in decreased dental care to soldiers  Contractors need their own civilian dentist to treat civilian support personnel *OIF 2010  KBR contractors, Iraqi contractors and citizens, and detainees comprised a large portion of our patient base and often presented with complex medical problems that required treatment with certain types of medications or equipment  It should become a standard for deploying units to stock Medical Equipment Sets with insulin, glucometers, antihypertensive, psych meds, etc. *OIF 2010  MNC-I OPORD sets forth general rules for care for contractors, but does not address eligibility for optometry and pharmacy services  This should be specifically addressed in the Rules for Care *OIF 2010  1–15% of medical treatment facility visits are related to contractor health care – most common conditions include diabetes, hypertension, and hyperlipidemia. Numerous contractors come into theater with CENTCOM deemed nondeployable conditions such as malignancy, anticoagulant therapy, CAD, and CHF  This places a burden on an already busy medical staff. *OIF 2010  There is no current process to capture maintenance medicines for contractors to ensure adequate supply of medications in stock and also brings into question certain personnel’s fitness to deploy based on some chronic medication therapy  Recommendation was to have a better screening process for maintenance med requirements during Soldier Readiness Process and maintain a database of current theater requirements based off of this. **OEF, Afghanistan 2010  *Operation Iraqi Freedom. **Operation Enduring Freedom. Table III provides composite health care system (CHCS) appointment data from the Camp Bondsteel Clinic from March 2015 through February 2016. Medical appointments for deployed US contractors comprised 12% of all medical visits. Medical information to assess patient acuity other than prescription data was not available for analysis. At the present time, U.S. Army Europe medical planners do not consider contract requirements when determining the medical footprint for Kosovo.5 Two factors are attributed to the decision to exclude the medical requirements of deployed contractors. First, medical support requirements for this patient population is thought to be negligible and within the capabilities of the existing footprint. Second, the Soldier Readiness Process screens out contractors with chronic medical conditions not conducive for a deployed environment with exceptions only possible through a waiver process. However, it is clear from our review of prescription data that logistical and care coordination grows increasingly complex as US Forces assume chronic care responsibilities for DOD contractors. Table III. Kosovo Quarterly Patient Appointment Data, March 15–February 16 Patient Detail  Appointment Status  March to May 15  June to August 15  September to November 15  December 15 to February 16  Total  Active duty  Sick call  58  111  87  40  296  Phone consult  10  3  2  3  18  Walk in  372  420  751  511  2054  Active duty dependent  Sick call  2  1  3  1  7  Phone consult  0  0  0  0  0  Walk in  1  2  7  8  18  Contractor  Sick call  11  11  21  4  47  Phone consult  0  1  0  1  2  Walk in  54  42  47  46  189  Retired  Sick call  2  7  4  1  14  Phone consult  0  0  2  2  4  Walk in  15  15  19  17  66    Total  525  613  943  634  2715    % Contractor + retired  16  12  10  11  12  Patient Detail  Appointment Status  March to May 15  June to August 15  September to November 15  December 15 to February 16  Total  Active duty  Sick call  58  111  87  40  296  Phone consult  10  3  2  3  18  Walk in  372  420  751  511  2054  Active duty dependent  Sick call  2  1  3  1  7  Phone consult  0  0  0  0  0  Walk in  1  2  7  8  18  Contractor  Sick call  11  11  21  4  47  Phone consult  0  1  0  1  2  Walk in  54  42  47  46  189  Retired  Sick call  2  7  4  1  14  Phone consult  0  0  2  2  4  Walk in  15  15  19  17  66    Total  525  613  943  634  2715    % Contractor + retired  16  12  10  11  12  Table III. Kosovo Quarterly Patient Appointment Data, March 15–February 16 Patient Detail  Appointment Status  March to May 15  June to August 15  September to November 15  December 15 to February 16  Total  Active duty  Sick call  58  111  87  40  296  Phone consult  10  3  2  3  18  Walk in  372  420  751  511  2054  Active duty dependent  Sick call  2  1  3  1  7  Phone consult  0  0  0  0  0  Walk in  1  2  7  8  18  Contractor  Sick call  11  11  21  4  47  Phone consult  0  1  0  1  2  Walk in  54  42  47  46  189  Retired  Sick call  2  7  4  1  14  Phone consult  0  0  2  2  4  Walk in  15  15  19  17  66    Total  525  613  943  634  2715    % Contractor + retired  16  12  10  11  12  Patient Detail  Appointment Status  March to May 15  June to August 15  September to November 15  December 15 to February 16  Total  Active duty  Sick call  58  111  87  40  296  Phone consult  10  3  2  3  18  Walk in  372  420  751  511  2054  Active duty dependent  Sick call  2  1  3  1  7  Phone consult  0  0  0  0  0  Walk in  1  2  7  8  18  Contractor  Sick call  11  11  21  4  47  Phone consult  0  1  0  1  2  Walk in  54  42  47  46  189  Retired  Sick call  2  7  4  1  14  Phone consult  0  0  2  2  4  Walk in  15  15  19  17  66    Total  525  613  943  634  2715    % Contractor + retired  16  12  10  11  12  Table IV shows the overall CHCS breakdown of prescription volume by patient category from the Camp Bondsteel Kosovo Pharmacy from March 2015 to February 2016. Our data show that 16% of the prescriptions are attributable to the contractors. However, as in the cases noted above, the quantity of prescriptions does not represent the whole story as the acuity of the illness is typically higher among contractor visits versus active duty. Further, even caring for retirees is not historically a typical mission for deployed medical assets operating at a role 1 level. Table IV. Kosovo Prescription Volume and Percentage Kosovo Prescription Data (March 15–February 16)        Total Rx  %  Active duty  2157  83  Active duty dependents  22  1  Retired  139  5  Other  298  11  Total  2616    Kosovo Prescription Data (March 15–February 16)        Total Rx  %  Active duty  2157  83  Active duty dependents  22  1  Retired  139  5  Other  298  11  Total  2616    Note: Active duty dependent’s Rx’s were likely coded in CHCS incorrectly. The retired and other categories represent Rx’s for DOD contractors. Table IV. Kosovo Prescription Volume and Percentage Kosovo Prescription Data (March 15–February 16)        Total Rx  %  Active duty  2157  83  Active duty dependents  22  1  Retired  139  5  Other  298  11  Total  2616    Kosovo Prescription Data (March 15–February 16)        Total Rx  %  Active duty  2157  83  Active duty dependents  22  1  Retired  139  5  Other  298  11  Total  2616    Note: Active duty dependent’s Rx’s were likely coded in CHCS incorrectly. The retired and other categories represent Rx’s for DOD contractors. Medical Commander Perspective The pharmacy was a very visible area that was affected by the contractor population, but it is part of a larger set of stressors on the limited medical assets that may also be worthy of further exploration. As noted in the findings section of this paper, contractors often do not consult with a primary care provider in coordinating their medications; we have also noted cases where they may wait for a provider to “rotate out” and potentially find a replacement who may be more favorable to their requests for certain treatment regimens. There are currently seven different contractors employing US personnel on Camp Bondsteel. Depending on the terms of their contract, different sets of the population have different rules for eligibility and reimbursement of medical treatment. In addition, some contractor employees are retired military personnel (making them eligible for full medical benefits above other employees of the same company), and some of the contractors employ local national personnel (who are eligible for emergency care in cases of life, limb, or eyesight only). The task force’s pharmacy and patient administration sections, who also rotate every 9 mo, must remain vigilant to ensure that contractor encounters are properly coded and that additional costs of treating this population including high-cost medications is captured and recouped by the army. Discussion With the 2015 Joint Chiefs of Staff projections of reduction in end strength of the Active Component, the National Guard and Army Reserve, it seems likely that the reliance on contractor support will continue at or near current levels. In fact, Pentagon predictions are that with the current drawdown, requirements, at least for security contractors, will increase significantly.6 With contractors already representing greater than 50% of the deployed DOD force, leaders, planners, and contract reviewers must consider the legal and logistical impact on pharmacy operations in theater. As contractor dependence is not likely to decrease, solutions such as carve outs or strategies for off-ramping contractor pharmaceutical care need to be considered. It is our experience that DOD contractors will seek military care regardless of contract stipulations. Mission planners instead may want to include contract medical care requirements as part of medical planning efforts. Such actions should include capability to provide chronic care management and associated medications. Further, considerations for the retrograding and termination of pharmacy services need the attention of medical planners when diminishing a medical footprint. Finally, as the army continues to employ large numbers of contractors in war zones, the American public is being introduced to this topic in the media. In the Frontline documentary Private Warriors, Peter Singer documents the increased reliance on contractor support and the cost implications.7 Although pharmacy services and costs are not specifically addressed in this documentary or the media as of yet, it is likely a future topic given the high costs and seemingly divergent mission of army pharmacy to support these contractors. It is tempting to think that army leaders can continue to make contractor decisions in a vacuum, without consideration of the impact on medical support requirements. However, this is probably not a valid assumption. The quandary is that army pharmacy is saddled with complicated automation and inventory to support these contractors. Furthermore, as the DOD mission winds down, the pharmacy mission could inversely rise as it is likely that contractors will remain in the theaters of operations, at least in the near term. Limitations One of the limitations of the current review is that CHCS does not account for the deployed prescription program Rx’s for contractors that were moved to mail order during deployment. Also, other sources of prescriptions, such as the Veterans Affairs mail order program, are not accounted for. We estimate that at least half of the contractor Rx’s for chronic medications were obtained outside of the CHCS system. Contractor Rx data are thus likely underrepresented. Conclusion We found that contractors were serving in the Balkan theater at a greater than 1:1 ratio of contractors to soldiers. In most cases, contractors were eligible for medical and pharmacy care from our deployed assets. Contractors in Kosovo were typically older than deployed soldiers and thus their pharmaceutical needs were more complex. This complicated our pharmacy operation, which on the one hand was trying to retrograde as the mission wound down, yet, on the other hand, had to expand to a more complex medication footprint to support the DOD contractors in theater. Acknowledgments The authors would like to acknowledge Mr. Kevin Book, MBA, Program Analysis and Evaluation Division, USAMEDCOM, and LTC Johnny Ray, APA-C, Clinical Operations, U.S. Army Europe, for their assistance in the preparation and review of this article. References 1 Schwartz M: Department of Defense’s use of Contractors to support Military Operations: Background, Analysis and Issues for Congress: 1(1). Available at https://www.fas.org/sgp/crs/natsec/R43074.pdf; accessed December 22, 2016. 2 Hammes TX: Private Contractors in Conflict Zones, the Good, the Bad, and the Strategic Impact, Strategy Forum – National Defense University: 1(1). Available at http://psm.du.edu/media/documents/reports_and_stats/think_tanks/inss_hammes-private-contractors.pdf; accessed December 22, 2016. 3 Operational Contract Support. Joint Publication 4–10. V-1(1): July 2014. Available at http://www.dtic.mil/doctrine/new_pubs/jp4_10.pdf; accessed December 22, 2016. 4 USCENTCOM, MOD-12 Individual Protection and Individual-Unit Deployment Policy, 15.C.1.E. Available at http://www.public.navy.mil/ia/dha/Documents/USCENTCOM_MOD_TWELVE.pdf; accessed July 7, 2017. 5 Mulally KJ (Exec Dir Office of Command Surgeon General): “Re: Kosovo RFI from Pharm” Message to John Spain. September 20, 2016. 6 Contractor Support of US Operations in the USCENTCOM Area of Responsibility: Pentagon Report to Congress January 2016. Available at http://www.acq.osd.mil/log/PS/.CENTCOM_reports.html/5A_January_2016_Final.pdf; accessed December 24, 2016. 7 PBS-Frontline Documentaries Video: Private Warriors. Available at https://www.youtube.com/watch?v=WSUnFPVjVpg; accessed May 2, 2017. Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.

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Military MedicineOxford University Press

Published: Jan 1, 2018

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