Prescription Drugs: Department of Veterans Affairs Paid About Half as Much as Medicare Part D for Selected Drugs in 2017

What GAO Found

GAO found that the Department of Veterans Affairs (VA) paid, on average, 54 percent less per unit for a sample of 399 brand-name and generic prescription drugs in 2017 as did Medicare Part D, even after accounting for applicable rebates and price concessions in the Part D program. GAO also found that 233 of the 399 drugs in the sample were at least 50 percent cheaper in VA than in Medicare, and 106 drugs were at least 75 percent cheaper. Only 43 drugs were cheaper in Medicare than in VA. The percent difference in price between the two programs was greater on average for generic drugs. Specifically, VA’s prices were 68 percent lower than Medicare prices for the 203 generic drugs (an average difference of $0.19 per unit) and 49 percent lower for the 196 brand-name drugs (an average difference of $4.11 per unit).

Average Per-Unit Net Prices Paid by Department of Veterans Affairs and Medicare Part D for Selected Drugs, 2017

Note: GAO’s sample of 399 drugs included the top 100 brand-name and generic drugs in Medicare Part D in 2017, by: (1) highest expenditures; (2) highest utilization (by quantities dispensed); and (3) highest cost-per use. Per-unit prices are weighted to reflect differences in utilization in the two programs. Medicare prices reflect expenditures after accounting for rebates and other price concessions.

While there are many factors that impact prices in the complex drug market, GAO identified several key program features that may contribute to the consistent price differential between VA and Medicare Part D. For example, Medicare’s beneficiaries are divided among numerous prescription drug plans, which each negotiate drug prices with manufacturers. In contrast, VA is a single integrated health system with a unified list of covered drugs—thereby possibly strengthening its bargaining position when negotiating. In addition, VA has access to significant discounts defined by law, and can then negotiate further for lower prices. These discount prices are not available to Medicare Part D plans.

GAO provided a draft of this product to HHS and VA for comment. Both agencies provided technical comments, which GAO incorporated as appropriate.

Why GAO Did This Study

In 2017, combined, Medicare Part D and VA accounted for approximately $105 billion in prescription drug sales—nearly one-third of total U.S. expenditures—and covered nearly 52 million individuals. The two programs use different methods to pay for prescription drugs. Medicare reimburses Part D plan sponsors, which in turn pay pharmacies to dispense drugs. VA primarily uses a direct purchase approach to acquire drugs from manufacturers.

GAO was asked to examine differences in the amounts major federal programs paid for prescription drugs. This report: (1) compares average unit prices for prescription drugs in Medicare Part D to those in the VA; and (2) describes factors affecting prices in the two programs.

GAO analyzed (1) CMS data for Medicare Part D payments to retail pharmacies as well as rebates and other price concessions Part D plans received and (2) VA drug purchasing data. These data were from 2017, the most recent data available at the time of GAO’s analysis. To select a sample of drugs GAO identified the top 100 brand-name and 100 generic drugs in Medicare Part D in 2017 for three categories: (1) highest expenditure, (2) highest utilization, and (3) highest cost-per use. In total, this yielded 399 non-duplicate drugs (203 generic and 196 brand-name), which represented 44 percent of Medicare Part D spending in 2017. GAO compared weighted average unit prices for these drugs. GAO interviewed CMS and VA officials, and reviewed academic and government reports to understand factors that may affect prices in the two programs.

For more information, contact John Dicken at (202) 512-7114 or dickenj@gao.gov.

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    Cognosante LLC has agreed to pay the United States $18,987,789 to resolve allegations that it violated the False Claims Act by using unqualified labor and overcharging the United States for services provided to government agencies under two General Services Administration (GSA) contracts, the Justice Department announced today.  Cognosante, which is headquartered in Falls Church, Virginia, provides health care and IT services and solutions to federal agencies.   
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  • Tax Administration: Better Coordination Could Improve IRS’s Use of Third-Party Information Reporting to Help Reduce the Tax Gap
    In U.S GAO News
    Information returns are forms filed by third parties, such as employers and financial institutions that provide information about taxable transactions. These forms are submitted to the Internal Revenue Service (IRS), the Social Security Administration, and taxpayers. Fifty unique types of information returns provide information on individual taxpayers and have a variety of purposes, such as reporting on wages earned or amounts paid that qualify for a tax credit or deduction. IRS identifies mismatches between information returns and tax returns for potential additional review, including enforcement actions. According to IRS research, taxpayers are more likely to misreport income when little or no third-party information reporting exists than when substantial reporting exists. Overview of Internal Revenue Service's (IRS) Process for Matching Information Returns IRS's ability to process and use information returns is limited by its outdated legacy information technology (IT) systems. In 2017, IRS developed a plan to modernize its information return processing systems; however, IRS paused its efforts due to, according to IRS, resource constraints. IRS has an opportunity to capitalize on prior planning efforts by re-evaluating and updating these efforts and integrating them into its broader IT modernization efforts. IRS does not have a coordinated approach with cross-agency leadership that strategically considers how information reporting could be improved to promote compliance with the tax code. While information returns affect many groups across IRS and support multiple compliance programs, no one office has broad responsibility for coordinating these efforts. A formalized collaborative mechanism, such as a steering committee, could help provide leadership and ensure that IRS acts to address issues among the intake, processing, and compliance groups. For example, IRS has not undertaken a broad review of individual information returns to determine if thresholds, deadlines, or other characteristics of the returns continue to meet the needs of the agency. For tax year 2018, IRS received and processed more than 3.5 billion information returns that it used to facilitate compliance checks on more than 150 million individual income tax returns. By matching information reported by taxpayers against information reported by third parties, IRS identifies potential fraud and noncompliance. GAO was asked to review IRS's use of information returns. This report provides an overview of information returns and assesses the extent to which IRS has a coordinated approach to identifying and responding to risks related to the use of information returns in the tax system, among other objectives. GAO reviewed IRS documents and data on information returns filing, processing, and use, and interviewed cognizant officials. GAO compared IRS's efforts in this area to federal internal control standards, and IRS's strategic plan. GAO is making nine recommendations to IRS, including that IRS revise its modernization plans for its information returns processing systems and incorporate it into broader IT modernization efforts and develop a collaborative mechanism to improve coordination among IRS groups that use information returns. IRS neither agreed, nor disagreed with the recommendations; however, IRS outlined actions it plans to take to address the recommendations. Social Security Administration had no comments. For more information, contact James R. McTigue at (202) 512-9110 or McTigueJj@gao.gov.
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  • Serbian Founder of Digital-Asset Companies Indicted in International Cryptocurrency Scheme
    In Crime News
    A Serbian man was charged in an indictment today for his alleged participation in a coordinated cryptocurrency scheme in which he solicited U.S. investors using two fraudulent online investment platforms.
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  • Three Individuals Affiliated With the Oath Keepers Indicted in Federal Court for Conspiracy to Obstruct Congress on Jan. 6, 2021
    In Crime News
    Three individuals associated with the Oath Keepers, a paramilitary organization focused on recruitment of current and former military, law enforcement, and first responder personnel, were indicted today in federal court in the District of Columbia for conspiring to obstruct Congress, among other charges.
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  • Singaporean National Sentenced to 14 Months in Prison for Acting in the United States As an Illegal Agent of Chinese Intelligence
    In Crime News
    Jun Wei Yeo, also known as Dickson Yeo, was sentenced today in federal court to 14 months in prison. Yeo pled guilty on July 24, 2020 to acting within the United States as an illegal agent of a foreign power without first notifying the Attorney General, in violation of 18 U.S.C. § 951. The announcement was made by John G. Demers, Assistant Attorney General; Michael R. Sherwin, Acting United States Attorney for the District of Columbia; James A. Dawson, Acting Assistant Director in Charge of FBI Washington Field Office; Alan E. Kohler, Jr., Assistant Director of the FBI's Counterintelligence Division; and Deputy Assistant Secretary Ricardo Colón, Domestic Operations Deputy Assistant Secretary Ricardo Colón, Domestic Operations.
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  • North Carolina Sport Supplement Company and Its Owner Plead Guilty to Unlawful Distribution of Steroid-like Drugs
    In Crime News
    A North Carolina resident and his sport supplement company pleaded guilty today to a felony charge relating to the introduction of unapproved new drugs into interstate commerce, the Department of Justice announced.
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  • Nuclear Waste: Congressional Action Needed to Clarify a Disposal Option at West Valley Site in New York
    In U.S GAO News
    The Department of Energy (DOE) has made progress in cleaning up radioactive waste at the site of the West Valley Demonstration Project in New York State. In the 1960s and 1970s, a commercial facility at the site reprocessed spent (used) nuclear fuel into reusable nuclear material—creating various wastes that remained on-site after the facility closed in 1976. Since 2011, DOE has demolished 51 of 55 structures there and disposed of about 1.3 million cubic feet of low-level waste to off-site locations. It has also placed solidified high-level waste into interim on-site storage (see fig.). In addition, DOE has processed for interim on-site storage about 30,000 cubic feet of transuranic waste (which is contaminated with elements that have an atomic number greater than uranium). As of February 2020, DOE reported spending about $3.1 billion on contracted cleanup activities, but it cannot estimate the cleanup's final cost until it decides how it will address the remaining waste. High-Level Waste from the West Valley Demonstration Project in Interim On-Site Storage, March 2017 DOE has been unable to dispose of the high-level and transuranic wastes stored at West Valley because there are no facilities authorized to accept these wastes. DOE has identified two potential options for disposal of the transuranic waste: the federal Waste Isolation Pilot Plant in New Mexico and a commercial facility in Texas. However, the New Mexico facility is authorized to accept only waste from atomic energy defense activities, and DOE does not consider West Valley waste to be from atomic energy defense activities. Regarding the Texas facility, state regulations preclude disposal of the waste there. In 2017, DOE submitted to Congress a report on all disposal options, as required by the Energy Policy Act of 2005. Pursuant to this act, DOE must await action by Congress before making a final decision, and Congress has not yet acted. The West Valley Demonstration Project Act, enacted in 1980, requires DOE to assist with cleanup activities at the site of the nation's only commercial facility for reprocessing spent nuclear fuel. The site contained 600,000 gallons of liquid high-level waste, radioactively contaminated structures and soils, and buried radioactive waste. In 2011, DOE began the first phase of its decommissioning plan, which included demolishing above-ground structures and removing contaminated soils. The West Valley Reauthorization Act and the Senate Committee Report No. 116-48 included provisions for GAO to review progress on the cleanup at West Valley. GAO's report examines (1) the status of the cleanup and (2) DOE's options for disposing of the remaining radioactive waste. GAO reviewed DOE's data on cleanup costs and waste volumes and its decommissioning plans, as well as laws, regulations, and policies governing radioactive waste disposal. GAO also interviewed officials from DOE and the state of New York, as well as other stakeholders. Congress should consider taking action to provide a legal option for the disposal of West Valley's transuranic waste. For more information, contact Allison Bawden at (202) 512-3841 or BawdenA@gao.gov.
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  • Close Air Support: Actions Needed to Enhance Friendly Force Tracking Capabilities and Fully Evaluate Training
    In U.S GAO News
    The Department of Defense (DOD) has made progress implementing initiatives to enhance capabilities that are used to identify friendly force locations during close air support (CAS) missions, but GAO identified additional actions that are needed to strengthen these efforts. Specifically, DOD has made limited progress in implementing 10 changes the department approved to address gaps in the interoperability of digital communications systems used to conduct CAS, hindering efforts to improve the speed and accuracy of information exchanges. DOD's efforts to assess the interoperability of digital systems used to perform CAS have been limited in scope. GAO found that DOD had formally assessed two out of 10 approved changes during joint service and multinational events, and these assessments were not conducted in a training environment that replicated capabilities of near-peer adversaries. DOD implemented a new capability in the U.S. Central Command area of responsibility to help identify the positions of friendly forces during CAS missions. However, GAO found that DOD did not provide adequate training for personnel who operate it or conduct an evaluation to resolve implementation challenges that have hampered its performance. DOD conducts evaluations of training programs for forces that participate in CAS missions, but GAO identified two areas where DOD can improve its efforts. First, the Army and Marine Corps have not systematically evaluated the effectiveness of periodic training for ground observers providing targeting information due to a lack of centralized systems for tracking training data and the absence of designated entities to monitor service-wide training. Second, the use of contract aircraft for training increased substantially between 2017 and 2019, but DOD has not fully evaluated the use of non-military contract aircraft to train air controllers for CAS (see fig.). GAO found that differences between U.S. military aircraft and contract aircraft (e.g., airspeed) can result in a misalignment of aircraft capabilities for certain types of training events. Without evaluating CAS training fully, DOD cannot have assurance that its forces are prepared to conduct CAS missions safely and effectively. Number of Hours Non-Military Aircraft Were Used to Train for Close Air Support for Fiscal Years 2017 through 2019 The use of ordnance delivered by aircraft to support U.S. military forces that are in close proximity to enemy forces on the ground requires detailed planning, seamless communications, and effective training. Mistakes in communications or procedures used to identify and maintain an awareness of the positions of friendly forces on the battlefield during CAS can result in the loss of U.S. military personnel. Senate Report 116-48 and House Report 116-120, accompanying bills for the National Defense Authorization Act for Fiscal Year 2020, included provisions for GAO to evaluate issues related to friendly-force identification capabilities in CAS missions. Among other things, this report evaluates the extent to which DOD has (1) implemented initiatives to enhance friendly-force identification capabilities during CAS, and (2) evaluated training for forces that participate in CAS. GAO analyzed documentation and interviewed officials regarding DOD efforts to develop and implement friendly force tracking capabilities for CAS; reviewed CAS training programs; and analyzed training data, including the number of hours that DOD used non-military contract aircraft for CAS training from 2017 through 2019. GAO is making 11 recommendations to DOD, including that DOD implement and assess initiatives to improve the interoperability of digital systems used in CAS and take additional steps to evaluate the training for certain forces that participate in CAS missions. DOD concurred with the recommendations. For more information, contact Cary Russell at (202) 512-5431 or RussellC@gao.gov.
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