Veterans Administration Drug Packaging Policy Touches Off Dispute

MEDFORD, Ore. (AP) -- Kathy Ellena looks out for her father these days just like he looked out for her when she couldn't take care of herself.
Her dad, Thaine High, is 92 and his memory has slipped a bit, but he still recalls his days in World War II as a graves registration officer, recovering the bodies of fallen American soldiers.
"All I did was pick up the dead," he said, talking with a visitor at Avamere at Waterford, an assisted-living center in Medford where he now resides. "I did that in Germany and Belgium and Luxembourg."
Like most men his age, High takes a number of medicines for his health problems. He used to get the drugs for free from the Department of Veterans Affairs because he has a service-related disability, but things changed when his dementia worsened and he could no longer take his drugs without supervision.
For patients like High who need help with their medicines, Waterford will dispense only drugs that are sealed in individual doses commonly known as blister packs or bubble packs. The VA won't bubble-pack drugs, so Ellena has no choice but to buy her dad's prescriptions through Medicare. She said she's paying $300 to $400 a month for drugs that her dad should be getting for free as a result of his service-related disability.
"I can't understand this," Ellena said. "This is insane."
Ellena wrote letters to Congress, the VA and pharmacies trying to find a solution. Managers at Avamere at Waterford told her they have to bubble-pack drugs to comply with state rules for medication safety. The VA told her it wasn't feasible to purchase bubble-pack equipment for veterans who live in non-VA care centers.
The VA offered to send the drugs to a pharmacy for bubble-packing, but the pharmacy told Ellena it wouldn't repackage drugs from the VA because the pharmacy was unwilling to accept the liability it would incur from repackaging. Ellena offered to bubble-pack her dad's drugs from the VA and give them to Waterford, but repackaging drugs is illegal.
"It's the minutiae that just drives you nuts," Ellena, a retired nurse, said Friday. "It's like health care reform around and around and around, and nothing gets done."
The people Ellena spoke with during her quest often told her they had heard similar stories before. She began to realize her dad's problem was far more common than she imagined, but just how widespread is hard to say because there's no way to easily count the veterans who reside in assisted living centers or foster homes.
"This is not the first time this conversation has come up," said Jennifer Zanon, an investigator for the Oregon Board of Pharmacy. She said the board has discussed the issue, but is restricted by federal regulations, and state officials have no jurisdiction over the federal Food and Drug Administration or the VA.
Zanon said FDA rules do not allow pharmacies to repackage previously dispensed prescriptions. Care centers such as Waterford establish their own system for dispensing medication to residents to comply with state rules designed to protect patient safety and prevent drug theft.
"The idea is the facility can control how medicines are packaged," said Diana Norton, community based care program coordinator for the Oregon Department of Human Services. "It's their decision based on their staff and setup."
State rules do not specifically require bubble-packing, but for many care centers, bubble-packing is the safest, most efficient way to comply, said Leilani Kahananui, health care coordinator at Waterford.
"I know we're not the only ones who do it," she said.
Kahananui said bubble-packing is company policy at Avamere, a Wilsonville-based company that provides a range of living situations and care services in 30-some communities in Oregon and Washington.
Safety rules require medicines to be counted at the end of every shift. Kahananui said if pills were kept loose in a bottle, someone would have to count them individually three times a day, and any pills that touched the floor would have to be discarded. Blister packs make counting easier and eliminate waste. They also dramatically reduce the chance that narcotics will be stolen or misused.
Kahananui noted that the same problem surfaces for non-veterans who buy their medicines in bulk. When they can no longer take their medicines without supervision, their drugs need to be bubble-packed, too, if they're in assisted living.
After hearing from Ellena, Congressman Greg Walden's office contacted the VA's Southern Oregon Rehabilitation Center and Clinics on her behalf. Director Max McIntosh wrote to Walden that "it is not feasible to purchase an assortment of packaging equipment for veterans who live in non-VA facilities that choose to use special packaging, such as the specific bubble packaging requested."
Walden, a Republican, forwarded a copy of the same letter to Ellena, in which McIntosh wrote that she could get a 10-day emergency supply of drugs for her dad, but she did not contact the VA pharmacy because she did not see how that would provide a long-term solution for the problem.
The VA serves about 80,000 veterans in Oregon, including some 15,000 outpatients through the clinic in White City.
Ellena said she's fighting to get the VA to provide suitably packaged drugs not just for her dad, but for thousands of veterans from the Korea, Vietnam, Iraq and Afghanistan wars.
"I want other people to know they have to fight for this," she said. "If they can change and make their policy something different, hallelujah."