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entitled 'Questions for Record Related to the Benefits and Medical Care 
for Federal Civilian Employees Deployed to Afghanistan and Iraq' which 
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October 16, 2007: 

The Honorable Vic Snyder: 

Chairman: 

Subcommittee on Oversight and Investigations: 

Committee on Armed Services: 

House of Representatives: 

Subject: Questions for the Record Related to the Benefits and Medical 
Care for Federal Civilian Employees Deployed to Afghanistan and Iraq: 

It was a pleasure to appear before your Subcommittee on September 18, 
2007, to discuss the benefits and medical care for federal civilian and 
U.S. government contract employees deployed to Iraq and 
Afghanistan.[Footnote 1] This letter responds to your request that I 
provide answers to questions for the record from the hearing. The 
questions, along with my responses, follow. 

1. What are the congressional requirements for medical tracking of 
deployed military servicemembers and civilians? 

Following GAO's May 1997 report,[Footnote 2] Congress enacted 
legislation[Footnote 3] that required the Secretary of Defense to 
establish a medical tracking system to assess the medical condition of 
servicemembers before and after deployments to locations outside of the 
United States.Specifically, the legislation required the following: 

"(a) System Required--The Secretary of Defense shall establish a system 
to assess the medical condition of members of the armed forces 
(including members of the reserve components) who are deployed outside 
the United States or its territories or possessions as part of a 
contingency operation (including a humanitarian operation, peacekeeping 
operation, or similar operation) or combat operation. 

"(b) Elements Of System--The system described in subsection (a) shall 
include the use of predeployment medical examinations and 
postdeployment medical examinations (including an assessment of mental 
health and the drawing of blood samples) to accurately record the 
medical condition of members before their deployment and any changes in 
their medical condition during the course of their deployment. The 
postdeployment examination shall be conducted when the member is 
redeployed or otherwise leaves an area in which the system is in 
operation (or as soon as possible thereafter). 

"(c) Recordkeeping--The results of all medical examinations conducted 
under the system, records of all health care services (including 
immunizations) received by members described in subsection (a) in 
anticipation of their deployment or during the course of their 
deployment, and records of events occurring in the deployment area that 
may affect the health of such members shall be retained and maintained 
in a centralized location to improve future access to the records. 

"(d) Quality Assurance--The Secretary of Defense shall establish a 
quality assurance program to evaluate the success of the system in 
ensuring that members described in subsection (a) receive predeployment 
medical examinations and postdeployment medical examinations and that 
the recordkeeping requirements with respect to the system are met." 

This legislation was amended by a provision in the John Warner National 
Defense Authorization Act for Fiscal Year 2007.[Footnote 4] The current 
legislation amends elements of the system and the quality assurance 
program as well as adds criteria for referral for further evaluations 
and minimum mental health standards for deployment. Specifically, the 
current legislation requires the following: 

"(a) System Required--Not changed by the current legislation. 

"(b) Elements Of System--: 

(1) The system described in subsection (a) shall include the use of 
predeployment medical examinations and postdeployment medical 
examinations (including an assessment of mental health and the drawing 
of blood samples) to accurately record the medical condition of members 
before their deployment and any changes in their medical condition 
during the course of their deployment. The postdeployment examination 
shall be conducted when the member is redeployed or otherwise leaves an 
area in which the system is in operation (or as soon as possible 
thereafter). 

(2) The predeployment and postdeployment medical examination of a 
member of the armed forces required under paragraph (1) shall include 
the following: 

(A) An assessment of the current treatment of the member and any use of 
psychotropic medications by the member for a mental health condition or 
disorder. 

(B) An assessment of traumatic brain injury. 

"(c) RECORDKEEPING--Not changed by the current legislation. 

"(d) QUALITY ASSURANCE--: 

(1) The Secretary of Defense shall establish a quality assurance 
program to evaluate the success of the system in ensuring that members 
described in subsection (a) receive predeployment medical examinations 
and postdeployment medical examinations and that the recordkeeping 
requirements with respect to the system are met. 

(2) The quality assurance program established under paragraph (1) shall 
also include the following elements: 

(A) The types of healthcare providers conducting postdeployment health 
assessments. 

(B) The training received by such providers applicable to the conduct 
of such assessments, including training on assessments and referrals 
relating to mental health. 

(C) The guidance available to such providers on how to apply the 
clinical practice guidelines developed under subsection (e)(1) in 
determining whether to make a referral for further evaluation of a 
member of the armed forces relating to mental health. 

(D) The effectiveness of the tracking mechanisms required under this 
section in ensuring that members who receive referrals for further 
evaluations relating to mental health receive such evaluations and 
obtain such care and services as are warranted. 

(E) Programs established for monitoring the mental health of each 
member who, after deployment to a combat operation or contingency 
operations, is known--: 

(i) to have a mental health condition or disorder; or: 

(ii) to be receiving treatment, including psychotropic medications, for 
a mental health condition or disorder. 

"(e) Criteria For Referral For Further Evaluations--The system 
described in subsection (a) shall include--: 

(1) development of clinical practice guidelines to be utilized by 
healthcare providers in determining whether to refer a member of the 
armed forces for further evaluation relating to mental health 
(including traumatic brain injury); 

(2) mechanisms to ensure that healthcare providers are trained in the 
application of such clinical practice guidelines; and: 

(3) mechanisms for oversight to ensure that healthcare providers apply 
such guidelines consistently. 

"(f) Minimum mental health standards for deployment--: 

(1) The Secretary of Defense shall prescribe in regulations minimum 
standards for mental health for the eligibility of a member of the 
armed forces for deployment to a combat operation or contingency 
operation. 

(2) The standards required by paragraph (1) shall include the 
following: 

(A) A specification of the mental health conditions, treatment for such 
conditions, and receipt of psychotropic medications for such conditions 
that preclude deployment of a member of the armed forces to a combat 
operation or contingency operation, or to a specified type of such 
operation. 

(B) Guidelines for the deployability and treatment of members of the 
armed forces diagnosed with a severe mental illness or post traumatic 
stress disorder. 

(3) The Secretary shall take appropriate actions to ensure the 
utilization of the standards prescribed under paragraph (1) in the 
making of determinations regarding the deployability of members of the 
armed forces to a combat operation or contingency operation." 

2. What work has GAO conducted on this topic? 

Since the 1990s, GAO has highlighted shortcomings with respect to the 
Department of Defense's (DOD) ability to assess the medical condition 
of servicemembers both before and after their deployments. Following 
GAO's May 1997 report, Congress enacted legislation (codified at 10 
U.S.C.  1074f) that required the Secretary of Defense to establish a 
medical tracking system for assessing the medical condition of 
servicemembers before and after deployments. 

In September 2003, we reported that the Army and Air Force did not 
comply with DOD's force health protection and surveillance requirements 
for many servicemembers deploying in support of Operation Enduring 
Freedom in Central Asia and Operation Joint Guardian in 
Kosovo.[Footnote 5] Specifically, our review disclosed problems with 
the Army's and Air Force's implementation of DOD's force health 
protection and surveillance requirements in the following areas: (1) 
deployment health assessments, (2) immunizations and other 
predeployment requirements, and (3) the completeness of medical records 
and centralized data collection. Our September 2003 report also raised 
concerns over a lack of DOD oversight of departmentwide efforts to 
comply with health surveillance requirements. Specifically, we reported 
that an effective quality assurance program had not been established at 
the Office of the Assistant Secretary of Defense for Health Affairs or 
at the Offices of the Surgeons' General of the Army or Air Force to 
help ensure compliance with force health protection and surveillance 
policies. We believed that the lack of such a system was a major cause 
of the high rate of noncompliance and thus recommended that the 
department establish an effective quality assurance program to ensure 
that the military services comply with the force health protection and 
surveillance requirements for all servicemembers. The department 
concurred with our recommendation, and in January 2004 began 
implementation of its deployment health quality assurance program. 

In September 2004, we reported similar issues related to DOD's ability 
to effectively manage the health status of its reserve forces.[Footnote 
6] Specifically we noted that DOD's centralized database had missing 
and incomplete predeployment health assessment questionnaires because 
not all of the required health information collected from reserve 
component members had reached DOD's central data collection point. We 
recommended that the Secretary of Defense take steps to ensure that 
predeployment health assessment questionnaires are submitted to the 
centralized data collection point as required. DOD concurred with our 
recommendation and noted that revised guidance was currently in 
coordination to clarify the requirement for submitting predeployment 
health assessments to the centralized database. 

In November 2004, we reported that overall compliance with DOD's force 
health protection and surveillance policies for servicemembers who 
deployed in support of Operation Iraqi Freedom varied by service, by 
installation, and by policy requirement.[Footnote 7] At that time, we 
did not evaluate the effectiveness of DOD's deployment health quality 
assurance program because of the relatively short time of its 
implementation. 

In October 2005, we reported that evidence suggested that reserve 
component members have deployed into theater with preexisting medical 
conditions that could not be adequately addressed in theater.[Footnote 
8] We also reported that DOD had limited visibility over the health 
status of reserve component members after they are called to duty and 
is unable to determine the extent of care provided to those members 
deployed with preexisting medical conditions despite the existence of 
various sources of medical information. We recommended that the 
Secretary of Defense determine what preexisting medical conditions 
should not be allowed into specific theaters of operations and to take 
steps to ensure that each service component consistently utilizes these 
as criteria for determining the medical deployability of its reserve 
component members. We also recommended that the Secretary of Defense 
explore using existing tracking systems to track those who have 
treatable preexisting medical conditions in theater. DOD partially 
concurred with our recommendation concerning the identification of 
preexisting medical conditions that would preclude deployment and noted 
that the services had made advances in identifying some preexisting 
conditions that would preclude deployment, but also stated that due to 
the ever changing nature of theater of operations this list could never 
be fully comprehensive or fully enforceable. DOD also concurred with 
our recommendation pertaining to the use of existing tracking systems 
to track treatable preexisting medical conditions. Specifically, DOD 
indicated that ongoing refinements to these systems based on lessons 
learned would improve the documentation of medical conditions 
throughout the military services including information concerning 
reserve members with preexisting conditions. 

As we noted in our statement, our September 2006 report[Footnote 9] on 
DOD's policies concerning its federal civilians who have deployed in 
support of operations in Afghanistan and Iraq found that DOD has 
established force health protection and surveillance policies aimed at 
assessing and reducing or preventing health risks for its deployed 
federal civilian personnel; however, at the time of our review, the 
department lacked a quality assurance mechanism to ensure the 
components' full implementation of its policies. To strengthen DOD's 
force health protection and surveillance for its deployed federal 
civilians, we recommended that DOD establish an oversight and quality 
assurance mechanism to ensure that all components fully comply with its 
requirements. In February 2007, the Office of the Deputy Assistant 
Secretary of Defense for Force Health Protection and Readiness 
published a new instruction[Footnote 10] on force health protection 
quality assurance. This policy applies to military servicemembers, as 
well as applicable DOD and contractor personnel. The new policy 
requires the military services to implement procedures to monitor key 
force health protection elements such as pre-and post-deployment health 
assessments. In addition, the policy requires each military service to 
report its force health protection and quality assurance findings to 
the Assistant Secretary of Defense (Health Affairs) through the Deputy 
Assistant Secretary of Defense for Force Health Protection and 
Readiness. 

We further noted in our statement that, in our June 2007 
report[Footnote 11] on DOD's compliance with the legislative 
requirement to perform pre-and post-deployment medical examinations on 
servicemembers, DOD lacked a comprehensive oversight framework to help 
ensure effective implementation of its deployment health quality 
assurance program, which included specific reporting requirements and 
results-oriented performance measures to evaluate the services' 
adherence to deployment health requirements. Also, we noted in our 
statement that the department's new instruction and planned actions 
indicate that DOD is taking steps in the right direction. We stated and 
still believe that if the department follows through with its efforts, 
it will be responsive to several of our reports' recommendations to 
improve DOD's force health protection and surveillance for the Total 
Force. 

For additional information on our work on military and civilian 
personnel, and DOD health care issues, please contact me on (202) 512- 
3604 or farrellb@gao.gov. 

Signed by: 

Brenda S. Farrell: 

Director, Defense Capabilities and: 
Management: 

[End of section] 

Footnotes: 

[1] GAO, DOD Civilian Personnel: Medical Policies for Deployed DOD 
Federal Civilians and Associated Compensation for Those Deployed, GAO- 
07-1235T (Washington, D.C.: Sept. 18, 2007). 

[2] GAO, Defense Health Care: Medical Surveillance Improved Since Gulf 
War, but Mixed Results in Bosnia, GAO/NSIAD-97-136 (Washington, D.C.: 
May 13, 1997). 

[3] National Defense Authorization Act for Fiscal Year 1998, Pub. L. 
No. 105-85,  765 (1997) (codified at 10 U.S.C.  1074f). DOD 
established force health protection and surveillance policies aimed at 
assessing and reducing or preventing health risks for its deployed 
federal civilian personnel. 

[4] John Warner National Defense Authorization Act for Fiscal Year 
2007, Pub. L. No. 109-364,  738 (2006) (codified at 10 U.S.C.  
1074f). 

[5] GAO, Defense Health Care: Quality Assurance Process Needed to 
Improve Force Health Protection and Surveillance, GAO-03-1041 
(Washington, D.C.: Sept. 19, 2003). 

[6] GAO, Military Personnel: DOD Needs to Address Long-term Reserve 
Force Availability and Related Mobilization and Demobilization Issues, 
GAO-04-1031. (Washington, D.C.: Sept. 15, 2004). 

[7] GAO, Defense Health Care: Force Health Protection and Surveillance 
Policy Compliance Was Mixed, but Appears Better for Recent Deployments, 
GAO-05-120 (Washington, D.C.: Nov. 12, 2004). 

[8] GAO, Military Personnel: Top Management Attention Is Needed to 
Address Long-standing Problems with Determining Medical and Physical 
Fitness of the Reserve Force, GAO-06-105. (Washington. D.C.: Oct. 27, 
2005). 

[9] GAO, DOD Civilian Personnel: Greater Oversight and Quality 
Assurance Needed to Ensure Force Health Protection and Surveillance for 
Those Deployed, GAO-06-1085 (Washington, D.C.: Sept. 29, 2006). 

[10] DOD Instruction 6200.05, Force Health Protection (FHP) Quality 
Assurance Program, February 16, 2007. 

[11] GAO, Defense Health Care: Comprehensive Oversight Framework Needed 
to Help Ensure Effective Implementation of a Deployment Health Quality 
Assurance Program, GAO-07-831 (Washington, D.C.: June 22, 2007). 

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