This is the accessible text file for GAO report number GAO-03-437 entitled 'Defense Health Care: Army Needs to Assess the Health Status of All Early-Deploying Reservists' which was released on April 15, 2003. This text file was formatted by the U.S. General Accounting Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products’ accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. Report to Congressional Committees: United States General Accounting Office: GAO: April 2003: DEFENSE HEALTH CARE: Army Needs to Assess the Health Status of All Early-Deploying Reservists: Assessing Health Status of Army Reservists: GAO-03-437: GAO Highlights: Highlights of GAO-03-437, a report to Congressional Committees Why GAO Did This Study: During the 1990-1991 Persian Gulf War, health problems prevented the deployment of a significant number of Army reservists. To help correct this problem the Congress passed legislation that required reservists to undergo periodic physical and dental examinations. The National Defense Authorization Act for 2002 directed GAO to review the value and advisability of providing examinations. GAO also examined whether the Army is collecting and maintaining information on reservist health. GAO obtained expert opinion on the value of periodic examinations and visited seven Army reserve units to obtain information on the number of examinations that have been conducted. What GAO Found: Medical experts recommend periodic physical and dental examinations as an effective means of assessing health. Periodic physical and dental examinations for early-deploying reservists provide a means for the Army to determine their health status. Army early-deploying reservists need to be healthy to meet the specific demands of their occupations; examinations and other health screenings can be used to identify those who cannot perform their assigned duties. Without adequate examinations, the Army may train, support, and mobilize reservists who are unfit for duty. The Army has not consistently carried out the statutory requirements for monitoring the health and dental status of Army early-deploying reservists. At the early-deploying units GAO visited, approximately 66 percent of the medical records were available for review. For example, we found that about 68 percent of the required 2-year physical examinations for those over age 40 had not been performed and that none of the annual medical certificates required of reservists were completed by reservists and reviewed by the units. The Army’s automated health care information system does not contain comprehensive physical and dental information on early-deploying reservists. According to Army officials, in 2003 the Army plans to expand its system to maintain accurate and complete medical and dental information to monitor the health status of early-deploying reservists. What GAO Recommends: GAO recommends that the Secretary of Defense ensure that for early- deploying reservists * 5-year physical examinations for those under 40 and 2-year physical examinations for those over 40 are complete; * annual medical certificates are complete and that they are reviewed by the Army; and * annual dental examinations and needed treatments are complete. DOD concurred with the recommendations. www.gao.gov/cgi-bin/getrpt?GAO-03-437. To view the full report, including the scope and methodology, click on the link above. For more information, contact Marjorie E. Kanof at (202) 512-7101. [End of section] Contents: Letter: Results in Brief: Background: Periodic Physical and Dental Examinations Are Valuable for Assessing Health Status and Provide Beneficial Information to the Army: The Army Has Not Collected and Maintained All Required Medical and Dental Information on Early-Deploying Reservists: Conclusions: Recommendations for Executive Action: Agency Comments and Our Evaluation: Appendix I: Scope and Methodology: Appendix II: Army Physical Profile Rating Guide: Appendix III: Annual Medical Certificate: Appendix IV: Comments from the Department of Defense: Appendix V: GAO Contact and Staff Acknowledgments: GAO Contact: Acknowledgments: Related GAO Products: Table: Table 1: DOD Dental Classifications and Their Description: Abbreviations: DOD: Department of Defense: DNA: deoxyribonucleic acid: FEDS_HEAL: Federal Strategic Health Care Alliance: HHS: Department of Health and Human Services: HIV: human immunodeficiency virus: MMRB: ‘Military Occupational Specialty/Medical Retention Board: This is a work of the U.S. Government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. It may contain copyrighted graphics, images or other materials. Permission from the copyright holder may be necessary should you wish to reproduce copyrighted materials separately from GAO’s product. United States General Accounting Office: Washington, DC 20548: April 15, 2003: Congressional Committees: The Department of the Army (Army) is increasingly relying on its 560,000 reservists to supplement the capabilities of our nation’s active duty forces for peacetime support operations as well as for war.[Footnote 1] Of these reservists, approximately 90,000 are specifically designated as early-deploying reservists.[Footnote 2] Because of this designation, they are entitled to health benefits not afforded to other reservists. The remaining reservists--about 470,000- -become early-deploying reservists 75 days prior to their scheduled deployment date, at which time they are entitled to the same benefits afforded to those who are specifically designated as early-deploying reservists. When reservists were mobilized during the Persian Gulf War in 1990- 1991, the Army discovered that due to medical reasons or poor dental status a significant number of them could not be deployed or had their deployment delayed.[Footnote 3] In an effort to obviate similar problems, the Congress passed four statutory requirements to monitor the health status of those designated as early-deploying reservists. These requirements are in addition to two requirements that had been in place prior to the Persian Gulf War. To meet these requirements, the Army is to provide annual medical screenings, annual dental screenings, selected dental treatment, and for those over age 40, physical examinations every 2 years. Early-deploying reservists are required to disclose annually to the Army the status of their physical and dental condition, and those under age 40 are required to undergo a physical examination once every 5 years. These six requirements are used to help ensure that the reservists meet the military’s health standards so they are ready to perform their assigned duties. The National Defense Authorization Act for Fiscal Year 2002 directed that we obtain information on the value of periodic physical and dental examinations and determine the advisability of the statutory requirements for the Armyís early-deploying reservists. We also agreed with the committees of jurisdiction to determine if the Army is collecting and maintaining information on the health status of its early-deploying reservists. To answer these questions we focused our work on units that have been specifically designated as early-deploying reservists. We visited seven early-deploying U.S. Army Reserve units in the states of Georgia, Maryland, and Texas and reviewed all available medical and dental records of reservists assigned to those units. However, our analysis of the information gathered at these units is not projectable. We reviewed U.S. Army Reserve medical policies and regulations pertaining to early- deploying reservists. We also reviewed Army National Guard policies and procedures governing reservists’ health care but did not review medical or dental records at Army National Guard units. Additionally, we analyzed Army data showing the cost to perform periodic physical and dental examinations[Footnote 4] and to provide dental treatment. We reviewed studies from the Department of Defense (DOD) including its 1999 report to the Congress on ways to improve the medical and dental care provided to reservists.[Footnote 5] We also reviewed studies and information on the effectiveness of periodic physical and dental examinations published by the Department of Health and Human Services (HHS), the National Institutes of Health, the American Medical Association, the Academy of General Dentistry, and others. We interviewed DOD officials in the offices of the Assistant Secretary of Defense for Reserve Affairs and the Assistant Secretary for Health Affairs, and officials in the Office of the Surgeon General, U.S. Army Forces Command and the Office of the Surgeon General, U.S. Army Reserve Command to obtain information on the health care provided to Army early-deploying reservists. (For more on our scope and methodology, see app. I.) We conducted our work from May 2002 through April 2003 in accordance with generally accepted government auditing standards. Results in Brief: Periodic physical and dental examinations for early-deploying reservists are valuable for the Army because such examinations provide a means of determining reservists’ health status and ensuring the medical readiness of reserve forces. Medical experts recommend periodic physical and dental examinations as an effective means of assessing health. Because Army early-deploying reservists need to be healthy to meet the specific demands of their occupations, examinations and other health screenings can be used to identify those who cannot perform their assigned duties. Without adequate examinations, the Army runs the risk of mobilizing early-deploying reservists who cannot be deployed because of their health. In the case of early-deploying reservists who cannot be deployed, the Army loses not only the amount it invested in salaries and training but also the particular skill or occupation it was relying on to fill a specific military need. The Army has not consistently carried out the statutory requirements for monitoring the health and dental status of Army early-deploying reservists. At the seven U.S. Army Reserve early-deploying units we visited, approximately 66 percent of the medical records were available for our review. Army administrators told us that the remaining files were in transit, with the reservist, or on file at another location. Based on our review of available records, we found that about 13 percent of the 5-year physical examinations had not been performed, and none of the annual medical certificates had been completed by reservists and reviewed by the units. Furthermore, 49 percent of early- deploying reservists lacked a current dental examination and 68 percent of those over the age of 40 lacked a current biennial physical examination. In addition, the Army does not have an automated system for maintaining accurate and complete medical information on early- deploying reservists. We are recommending that the Secretary of Defense direct the Secretary of the Army to fully comply with the six statutory requirements. In commenting on a draft of this report, DOD concurred with the report’s recommendations. Background: In recent years, reservists have regularly been called on to augment the capabilities of the active-duty forces. The Army is increasingly relying on its reserve forces to provide assistance with military conflicts and peacekeeping missions. As of April 2003, approximately 148,000 reservists[Footnote 6] from the Army National Guard and the U.S. Army Reserve were mobilized to active duty positions. In addition, other reservists are serving throughout the world in peacekeeping missions in the Balkans, Africa, Latin America, and the Pacific Rim. The involvement of reservists in military operations of all sizes, from small humanitarian missions to major theater wars, will likely continue under the military’s current war fighting strategy and its peacetime support operations. The Army has designated some Army National Guard and U.S. Army Reserve units and individuals as early-deploying reservists to ensure that forces are available to respond rapidly to an unexpected event or for any other need. Usually, those designated as early-deploying reservists would be the first troops mobilized if two major ground wars were underway concurrently. The units and individual reservists designated as early-deploying reservists change as the missions or war plans change. The Army estimates that of its 560,000 reservists, approximately 90,000 are reservists who have been individually categorized as early-deploying reservists or are reservists who are assigned to Army National Guard and U.S. Army Reserve units that have been designated as early-deploying units. The Army must comply with the following six statutory requirements that are designed to help ensure the medical and dental readiness of its early-deploying reservists. * All reservists including early-deployers are required to: * have a 5-year physical examination,[Footnote 7] and: * complete an annual certificate of physical condition.[Footnote 8] * All early-deploying reservists are also required to have: * a biennial physical examination if over age 40,[Footnote 9] * an annual medical screening,[Footnote 10] * an annual dental screening,[Footnote 11] and: * dental treatment.[Footnote 12] Army regulations state that the 5-and 2-year physical examinations are designed to provide the information needed to identify health risks, suggest lifestyle modifications, and initiate treatment of illnesses. While the two examinations are similar, the biennial examination for early-deploying reservists over age 40[Footnote 13] contains additional age-specific screenings such as a prostate examination, a prostate- specific antigen test, and a fasting lipid profile that includes testing for total cholesterol, low-density lipoproteins, and high- density lipoproteins. The Army pays for these examinations. The examinations are also used to assign early-deploying reservists a physical profile rating, ranging from P1 to P4, in six assessment areas: (a) Physical capacity, (b) Upper extremities, (c) Lower extremities, (d) Hearing-ears, (e) Vision-eyes, and (f) Psychiatric. (See app. II for the Army’s Physical Profile Rating Guide.) According to the Army, P1 represents a non-duty-limiting condition, meaning that the individual is fit for duty and possesses no physical or psychiatric impairments. P2 means a condition may exist; however, it is not duty- limiting. P3 or P4 means that the individual has a duty-limiting condition in one of the six assessment areas. P4 means the individual functions below the P3 level. A rating of either P3 or P4 puts the reservist in a nondeployable status or may result in the changing of the reservist’s job classification. Beginning in January 2003, early-deploying reservists with a permanent rating of P3 or P4[Footnote 14] in one of the assessment areas must be evaluated by an administrative screening board--the Military Occupational Specialty/Medical Retention Board (MMRB). This evaluation determines if reservists can satisfactorily perform the physical requirements of their jobs. The MMRB recommends whether a reservist should retain a job, be reassigned, or be discharged from the military. Army regulations that implement the statutory certification requirement provide that all reservists--including early-deploying reservists-- certify their physical condition annually on a two-page certification form. Army early-deploying reservists must report doctor or dentist visits since their last examination, describe current medical or dental problems, and disclose any medications they are currently taking. (See app. III for a copy of the annual medical certificate--DA Form 7349.) In addition, the Army is required to conduct an annual medical screening for all early-deploying reservists. According to Army regulations, the Army is to meet the annual medical screening requirement by reviewing the medical certificate required of each early-deploying reservist. In addition, Army early-deploying reservists are required to undergo, at the Army’s expense, an annual dental examination. The Army is also required to provide and pay for the dental treatment needed to bring an early-deploying reservist’s dental status up to deployment standards-- either dental class 1 or 2. (See table 1 for a general description of each dental classification.): Table 1: DOD Dental Classifications and Their Description: Class 1: reservist is deployable: Reservists not requiring dental treatment or reevaluation within 12 months.; Class 2: reservist is deployable: Reservists who have oral conditions that, if not treated or followed up, have the potential but are not expected to result in dental emergencies within 12 months.; Class 3: reservist is nondeployable: Reservists who have oral conditions that if not treated are expected to result in dental emergencies within 12 months. Reservists should be placed in Class 3 when there are questions in determining classification between Class 2 and Class 3.; Class 4: reservist is nondeployable: Reservists who have not had the required annual dental examination.. Source: DOD. Note: DOD Policy Memorandum, Policies on Uniformity of Dental Classification System, Frequency of Periodic Dental Examinations, Active Duty Overseas Screening, and Dental Deployment Standards (Washington, D.C.: Feb.19, 1998). [End of table] According to Army officials, most of the 5-year and 2-year physical examinations, the dental examinations, and the dental treatments that have been performed were administered by military medical personnel. However, beginning in March 2001, the Army started outsourcing some examinations through the Federal Strategic Healthcare Alliance (FEDS_HEAL)--an alliance of private physicians and dentists and other physicians and dentists who work for the Department of Veterans Affairs and HHS’s Division of Federal Occupational Health. FEDS_HEAL is a program that allows Army early-deploying reservists to obtain required physical and dental examinations and dental treatment from local providers. The Army contracts and pays for these examinations. About 12,000 of these providers nationwide participate in FEDS_HEAL. The Army plans to increase its reliance on FEDS_HEAL to provide physical and dental examinations, and dental treatment for early-deploying reservists. Periodic Physical and Dental Examinations Are Valuable for Assessing Health Status and Provide Beneficial Information to the Army: Medical experts recommend physical and dental examinations as an effective means of assessing health. For some people, the frequency and content of physical examinations vary according to the specific demands of their job. Because Army early-deploying reservists need to be healthy to fulfill their professional responsibilities, periodic examinations are useful for assessing whether they can perform their assigned duties. Furthermore, the estimated annual cost to conduct periodic examinations--about $140--is relatively modest compared to the thousands of dollars the Army spends for salaries and training of early-deploying reservists--an investment that may be lost if reservists can not perform their assigned duties. Experts Look to Screenings and Examinations as Key Indicators of Health: Physical and dental examinations are geared towards assessing and improving the overall health of the general population. The U.S. Preventive Services Task Force[Footnote 15] and many other medical organizations no longer recommend annual physical examinations for adults--preferring instead a more selective approach to detecting and preventing health problems. In 1996, the task force reported that while visits with primary care clinicians are important, performing the same interventions annually on all patients is not the most clinically effective approach to disease prevention.[Footnote 16] Consistent with its finding, the task force recommended that the frequency and content of periodic health examinations should be based on the unique health risks of individual patients. Today, many health associations and organizations are recommending periodic health examinations that incorporate age-specific screenings, such as cholesterol screenings for men (beginning at age 35) and women (beginning at age 45) every 5 years, and clinical breast examinations every 3 to 5 years for women between the ages of 19 and 39. Further, oral health care experts emphasize the importance of regular 6-to 12-month dental examinations. Both the private and public sectors have established a fixed schedule of physical examinations for certain occupations to help ensure that workers are healthy enough to meet the specific demands of their jobs. For example, the Federal Aviation Administration requires commercial pilots to undergo a physical examination once every 6 months. U.S. National Park Service personnel who perform physically demanding duties have a physical examination once every other year for those under age 40, and on an annual basis for those over age 40. Additionally, guidelines published by the National Fire Protection Association recommend that firefighters have an annual physical examination regardless of age. In the case of Army early-deploying reservists, the goal of the physical and dental examinations is to help ensure that the reservists are fit enough to be deployed rapidly and perform their assigned jobs. Furthermore, the Army recognizes that some jobs are more demanding than others and require more frequent examinations. For example, the Army requires that aviators undergo a physical examination once a year, while marine divers and parachutists have physical examinations once every 3 years. While governing statutes and regulations require physical examinations at specific intervals, the Army has raised concerns about the appropriate frequency for them. In a 1999 report to the Congress, the Offices of the Assistant Secretaries of Defense for Health Affairs and Reserve Affairs stated that while there were no data to support the benefits of conducting periodic physical examinations, DOD was reluctant to recommend a change to the statutory requirements.[Footnote 17] The report stated that additional research was needed to identify and develop a more cost-effective, focused health assessment tool for use in conducting physical examinations for reservists--in order to ensure the medical readiness of reserve forces. However, as of February 2003, DOD had not conducted this research. Cost of Conducting Physical and Dental Examinations and Providing Dental Treatments: For its early-deploying reservists, the Army conducts and pays for physical and dental examinations and selected dental treatments at military treatment facilities or pays civilian physicians and dentists to provide these services. The Army could not provide us with information on the cost to provide these services at military hospitals or clinics primarily because it does not have a cost accounting system that records or generates cost data for each patient.[Footnote 18] However, the Army was able to provide us with information on the amount it pays civilian providers for these examinations under the FEDS_HEAL program. Using FEDS_HEAL contract cost information, we estimate the average cost of the examinations to be about $140 per early-deploying reservist per year. We developed the estimate over one 5-year period by calculating the annual cost for those early-deploying reservists requiring a physical examination once every 5 years, calculating the cost for those requiring a physical examination once every 2 years, and calculating the cost for those requiring an initial dental examination and subsequent yearly dental examinations.[Footnote 19] The FEDS_HEAL cost for each physical examination for those under 40 is about $291, and for those over 40 is about $370. The Army estimates that the cost of annual dental examinations under the program to be about $80 for new patients and $40 for returning patients. The Army estimates that it would cost from $400 to $900 per reservist to bring those who need treatment from dental class 3 to dental class 2. Benefits of Conducting Periodic Examinations: For the Army, there is likely value in conducting periodic examinations because the average cost to provide physical and dental examinations per early-deploying reservist--about $140 annually over a 5-year period--is relatively low compared to the potential benefits associated with such examinations. These examinations could help protect the Army’s investment in its early-deploying reservists by increasing the likelihood that more reservists will be deployable. This likelihood is increased when the Army uses examinations to identify early-deploying reservists who do not meet the Army’s health standards and are thus not fit for duty. The Army can then intervene by treating, reassigning, or dismissing these reservists with duty-limiting conditions--before their mobilization and before the Army needs to rely on the reservists’ skills or occupations. Furthermore, by identifying duty-limiting conditions or the risks for developing them, periodic examinations give early-deploying reservists the opportunity to seek medical care for their conditions--prior to mobilization. Periodic examinations may provide another benefit to the Army. If the Army does not know the health condition of its early-deploying reservists, and if it expects some of them to be unfit and incapable of performing their duties, the Army may be required to maintain a larger number of reservists than it would otherwise need in order to fulfill its military and humanitarian missions. While data are not available to estimate these benefits, the benefit associated with reducing the number of reservists the Army needs to maintain for any given objective could be large enough to more than offset the cost of the examinations and treatments. The proportion of reservists whom the Army maintains but who cannot be deployed because of their health may be significant. For instance, according to a 1998 U.S. Army Medical Command study, a “significant number” of Army reservists could not be deployed for medical reasons during mobilization for the Persian Gulf War (1990- 1991).[Footnote 20] Further, according to a study by the Tri-Service Center for Oral Health Studies at the Uniformed Services University of the Health Sciences, an estimated 25 percent of Army reservists who were mobilized in response to the events of September 11, 2001, were in dental class 3 and were thus undeployable.[Footnote 21] In fact, our analysis of the available current dental examinations at the seven early-deploying units showed a similar percentage of reservists--22 percent--who were in dental class 3.[Footnote 22] With each undeployable reservist, the Army loses, at least temporarily, a significant investment that is large compared to the cost of examining and treating these reservists. The annual salary for an Army early- deploying reservist in fiscal year 2001 ranged from $2,200 to $19,000. The Army spends additional amounts to train and equip each reservist and, in some cases, provides allowances for subsistence and housing. Additionally, for each reservist it mobilizes, the Army spends about $800.[Footnote 23] If it does not examine all of its early-deploying reservists, the Army risks losing its investment because it will train, support, and mobilize reservists who might not be deployed because of their health. The Army Has Not Collected and Maintained All Required Medical and Dental Information on Early-Deploying Reservists: The Army has not consistently carried out the requirements that early- deploying reservists undergo 5-or 2-year physical examinations, and the required dental examination. In addition, the Army has not required early-deploying reservists to complete the annual medical certificate of their health condition, which provides the basis for the required annual medical screening. Accordingly, the Army does not have current health information on early-deploying reservists. Furthermore, the Army does not have the ability to maintain information from medical and dental records and annual medical certificates at the aggregate or individual level, and therefore does not know the overall health status of its early-deploying reservists. Examinations Have Not Always Been Performed and Annual Medical Certificates Have Not Been Completed and Reviewed: We found that the Army has not consistently met the statutory requirements to provide early-deploying reservists physical examinations at 5-or 2-year intervals. At the seven Army early- deploying reserve units we visited, about 66 percent of the medical records were available for our review.[Footnote 24] Based on our review of these records, 13 percent of the reservists did not have a current 5-year physical examination on file. Further, the Army is also required to provide physical examinations every 2 years for Army early-deploying reservists over the age of 40. However, our review of the available records found that approximately 68 percent of early-deploying reservists over age 40 did not have a record of a current biennial examination. Army early-deploying reservists are required by statute to complete an annual medical certificate of their health status, and regulations require the Army to review the form to satisfy the annual screening requirement. In performing our review of the records on hand, we found that none of the units we visited required that its reservists complete the annual medical certificate, and consequently, none of them were available for review. Furthermore, Army officials stated that reservists at most other units have not filled out the certification form and that enforcement of this requirement was poor. The Army is also statutorily required to provide early-deploying reservists with an annual dental examination to establish whether reservists meet the dental standards for deployment. At the seven early-deploying units that we visited, we found that about 49 percent of the reservists whose records were available for review did not have a record of a current dental examination. Army’s Automated Systems Do Not Contain Comprehensive Health Information on Early-Deploying Reservists: The Army’s two automated information systems for monitoring reservists’ health do not maintain important medical and dental information for early-deploying reservists--including information on the early- deploying reservists’ overall health status, information from the annual medical certificate form, dental classifications, and the date of dental examinations. In one system, the Regional Level Application Software, the records provide information on the dates of the 5-year physical examination and the physical profile ratings. In the other system, the Medical Occupational Database System, the records provide information on HIV status, immunizations, and DNA specimens. Neither system allows the Army to review medical and dental information for entire units at an aggregate level. The Army is aware of the information shortcomings of these systems and acknowledges that having sufficient, accurate, and current information on the health status of reservists is critical for monitoring combat readiness. According to Army officials, in 2003 the Army plans to expand the Medical Occupational Database System to provide the Army with access to current, accurate, and relevant medical and dental information at the aggregate and individual levels for all of its reservists--including early-deploying reservists. According to Army officials, this information will be readily available to the U.S. Army Reserve Command. Once available, the Army can use this information to determine which early-deploying reservists meet the Army’s health care standards and are ready for deployment. Conclusions: Army reservists have been increasingly called upon to serve in a variety of operations, including peacekeeping missions and the current war on terrorism. Given this responsibility, periodic health examinations are important to help ensure that Army early-deploying reservists are fit for deployment and can be deployed rapidly to meet humanitarian and wartime needs. However, the Army has not fully complied with statutory requirements to assess and monitor the medical and dental status of early-deploying reservists. Consequently, the Army does not know how many of them can perform their assigned duties and are ready for deployment. The Army will realize benefits by fully complying with the statutory requirements. The information gained from periodic physical and dental examinations, coupled with age-specific screenings and information provided by early-deploying reservists on an annual basis in their medical certificates, will assist the Army in identifying potential duty-limiting medical and dental problems within its reserve forces. This information will help ensure that early-deploying reservists are ready for their deployment duties. Given the importance of maintaining a ready force, the benefits associated with the relatively low annual cost of about $140 to conduct these examinations outweighs the thousands of dollars spent in salary and training costs that are lost when an early-deploying reservist is not fit for duty. The Army’s planned expansion, in 2003, of an automated health care information system is critical for capturing the key medical and dental information needed to monitor the health status of early-deploying reservists. Once collected, the Army will have additional information to conduct the research suggested by DOD’s Offices of Health Affairs and Reserve Affairs to determine the most effective approach, which could include the frequency of physical examinations, for determining whether early-deploying reservists are healthy, can perform their assigned duties, and can be rapidly deployed. Recommendations for Executive Action: To help ensure that early-deploying reservists are healthy to carry out their duties, we recommend that the Secretary of Defense direct the Secretary of the Army to comply with existing statutory requirements to ensure that: * the 5-year physical examinations for early-deploying reservists under 40 and the biennial physical examinations for early-deploying reservists over 40 are current and complete, * all early-deploying reservists complete their annual medical certificate of health status and that the appropriate Army personnel review the certificate, and: * the required dental examinations and treatments for all early- deploying reservists are complete. Agency Comments and Our Evaluation: The Department of Defense provided written comments on a draft of this report, which are found in appendix IV. DOD concurred with the report’s recommendations. DOD raised some concerns about our evaluation. For example, DOD stated that the intermittent use of the terms “The Army,” “Reserve Component,” and “Army Reserve” would lead to a misunderstanding of the organization of Army Components. While DOD did not offer specific examples, we reviewed the draft to ensure that terms were used appropriately and did not make any changes. DOD also raised the concern that we used a very narrow subject group that may not reflect a valid representative sample and that the report findings could be incorrectly applied to the Army National Guard. As we noted in our draft report, our work was conducted at seven early deploying U.S. Army Reserve units--geographically dispersed in the states of Georgia, Maryland, and Texas--and our analysis of the information collected at these units is not projectable. Finally, DOD stated that methods for annually certifying physical conditions could also include completing the statement of physical condition that is preprinted on the Personnel Qualification Record, and that we did not consider whether such alternatives were used for certification. During our visits we reviewed the medical files at all locations, the personnel files at one location, and interviewed military personnel who were responsible for maintaining the records of early-deploying reservists at all locations. We were unable to find one annual medical certificate that was reviewed by military personnel to meet the statutory requirements. In addition, some military personnel were not aware of the requirement. We are sending copies of this report to the Secretary of Defense, appropriate congressional committees, and other interested parties. Copies will also be made available to others on request. In addition, the report is available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7101. Another contact and major contributors are listed in appendix V. Marjorie E. Kanof Director, Health Care--Clinical and Military Health Care Issues: Signed by Marjorie E. Kanof: List of Committees: The Honorable John Warner Chairman The Honorable Carl Levin Ranking Minority Member Committee on Armed Services United States Senate: The Honorable Ted Stevens Chairman The Honorable Daniel K. Inouye Ranking Minority Member Subcommittee on Defense Committee on Appropriations United States Senate: The Honorable Duncan Hunter Chairman The Honorable Ike Skelton Ranking Minority Member Committee on Armed Services House of Representatives: The Honorable Jerry Lewis: Chairman The Honorable John P. Murtha Ranking Minority Member Subcommittee on Defense Committee on Appropriations House of Representatives: [End of section] Appendix I: Scope and Methodology: We reviewed statutes and Army policies and regulations governing annual medical and dental screenings, and periodic physical and dental examinations. We obtained data from the Office of the Chief, U.S. Army Reserve on the physical and dental examinations performed since 2001 on early-deploying reservists. We reviewed our past reports that addressed medical and dental examinations. We conducted site visits to seven U.S. Army Reserve Units located in Georgia, Maryland, and Texas--where we obtained and reviewed all available medical and dental records. There were 504 early-deploying reservists assigned to the seven units we visited. Medical records for 332 reservists were available for our review. Army administrators told us that the remaining files were in transit, with the reservist, or on file at another location. Our analysis of the information gathered at these units is not projectable. We did not review medical or dental records at Army National Guard units, but obtained information from the Guard on its medical policies. To calculate an average annual cost to provide physical and dental examinations for Army early-deploying reservists, we obtained estimates from the Army’s Federal Strategic Healthcare Alliance (FEDS_HEAL) administrator on the costs of outsourcing the examinations. We calculated the annual cost for those reservists requiring a physical examination once every 5 years and those requiring a physical examination once every 2 years. In developing the annual cost estimate, we used DOD information on the number of Army reservists that are under 40 (approximately 75 percent), and those over 40 (approximately 25 percent). We also included the initial dental examination cost and subsequent yearly dental examination costs. All costs were averaged over one 5-year period. The average annual cost does not include allowances for inflation, dental treatment, or specialized laboratory fees such as those for pregnancy, phlebotomy, and tuberculosis. We also obtained estimates of the cost to perform dental treatments from the Army Office of the Surgeon General and Army Dental Command. We obtained from DOD, HHS’s Office of Public Health and Science, the Centers for Disease Control and Prevention, medical associations, and dental associations studies and information concerning the advisability of periodic physical and dental examinations. From these organizations we also obtained published common practices and standards concerning periodic medical and dental examinations, age and risk factors, and the value and relevance of patients’ self-reporting of symptoms. [End of section] Appendix II: Army Physical Profile Rating Guide: Table 2: Assessment areas: Physical capacity: Organic defects, strength, stamina, agility, energy, muscular coordination, function, and similar factors.; Assessment areas: Upper extremities: Strength, range of motion, and general efficiency of upper arm, shoulder girdle, and upper back, including cervical and thoracic vertebrae.; Assessment areas: Lower extremities: Strength, range of movement, and efficiency of feet, legs, lower back, and pelvic girdle.; Assessment areas: Hearing- ears: Auditory sensitivity and organic disease of the ears.; Assessment areas: Vision-eyes: Visual acuity and organic disease of the eyes and lids.; Assessment areas: Psychiatric: Type, severity, and duration of the psychiatric symptoms or disorder existing at the time the profile is determined. Amount of external precipitating stress. Predispositions as determined by the basic personality makeup, intelligence, performance, and history of past psychiatric disorder impairment of functional capacity.. Physical profile rating: P1; (Non-duty-limiting conditions); Assessment areas: Physical capacity: Good muscular development with ability to perform maximum effort for indefinite periods.; Assessment areas: Upper extremities: No loss of digits or limitation of motion; no demonstrable abnormality; able to do hand-to-hand fighting.; Assessment areas: Lower extremities: No loss of digits or limitation of motion; no demonstrable abnormality; able to perform long marches, stand over long periods, and run.; Assessment areas: Hearing-ears: Audiometer average level for each ear not more than 25 dB at 500, 1000, or 2000 Hz with no individual level greater than 30 dB. Not over 45 dB at 4000 Hz.; Assessment areas: Vision-eyes: Uncorrected vision acuity 20/200 correctable to 20/20 in each eye.; Assessment areas: Psychiatric: No psychiatric pathology; may have history of transient personality disorder.. Physical profile rating: P2; (Non-duty-limiting conditions); Assessment areas: Physical capacity: Able to perform maximum effort over long periods.; Assessment areas: Upper extremities: Slightly limited mobility of joints, muscular weakness, or other musculo- skeletal defects that do not prevent hand-to-hand fighting and do not disqualify for prolonged effort.; Assessment areas: Lower extremities: Slightly limited mobility of joints, muscular weakness, or other musculo-skeletal defects that do not prevent moderate marching, climbing, timed walking, or prolonged effort.; Assessment areas: Hearing-ears: Audiometer average level for each ear at 500, 1000, or 2000 Hz, not more than 30 dB, with no individual level greater than 35 dB at these frequencies, and level not more than 55 dB at 4000 Hz; or audiometer level 30 dB at 500 Hz, 25 dB at 1000 and 2000 Hz, and 35 dB at 4000 Hz in better ear. (Poorer ear may be deaf.); Assessment areas: Vision-eyes: Distant visual acuity correctable to not worse than 20/40 and 20/70, or 20/30 and 20/100, or 20/20 and 20/400.; Assessment areas: Psychiatric: May have history of recovery from an acute psychotic reaction due to external or toxic causes unrelated to alcohol or drug addiction.. Physical profile rating: P3; (Duty-limiting; conditions); Assessment areas: Physical capacity: Unable to perform full effort except for brief or moderate periods.; Assessment areas: Upper extremities: Defects or impairments that require significant restriction of use.; Assessment areas: Lower extremities: Defects or impairments that require significant restriction of use.; Assessment areas: Hearing- ears: Speech reception threshold in best ear not greater than 30 dB HL measured with or without hearing aid, or chronic ear disease.; Assessment areas: Vision-eyes: Uncorrected distant visual acuity of any degree that is correctable to not less than 20/40 in the better eye.; Assessment areas: Psychiatric: Satisfactory remission from an acute psychotic or neurotic episode that permits utilization under specific conditions (assignment when outpatient psychiatric treatment is available or certain duties can be avoided).. Physical profile rating: P4; (Duty-limiting conditions); Assessment areas: Physical capacity: Functional level below P3.; Assessment areas: Upper extremities: Functional level below P3.; Assessment areas: Lower extremities: Functional level below P3.; Assessment areas: Hearing- ears: Functional level below P3.; Assessment areas: Vision-eyes: Functional level below P3.; Assessment areas: Psychiatric: Functional level below P3.. Source: Army. Note: Army Regulation 40-501, Mar. 28, 2002. [End of table] [End of section] Appendix III: Annual Medical Certificate: [See PDF for image] [End of figure] [End of section] Appendix IV: Comments from the Department of Defense: THE ASSISTANT SECRETARY OF DEFENSE: WASHINGTON, D. C. 20301-1200: HEALTH AFFAIRS: APR 3 2003: Ms. Majorie E. Kanof: Director, Health Care-Clinical and Military Health Care Issues General Accounting Office: Washington, D.C. 20548: Dear Ms. Kanof: This is the Department of Defense (DoD) response to the GAO draft report, “DEFENSE HEALTH CARE: Army Needs to Assess the Health Status of all Early Deploying Reservists,” dated February 28, 2003, (GAO Code 290179/GAO-03-437). The recommendations contained in the GAO’s report are restatements of existing statutory requirements. We certainly support and concur with these recommendations. Detailed comments are provided as an enclosure to this letter. The DoD does have some concerns with the GAO’s evaluation of the mobilization and deployment requirements for the Selected Reserve (SELRES) and the Army Reserve National Guard (ARNG). Our comments about the report’s methodology are: * The terms “The Army” [AC[USAR/ARNG], “Reserve Component” [USAR/ARNG], and “Army Reserve” [USAR] are intermittently used. This would lead to a misunderstanding of the organization of the Army Components. The GAO study was done with a very narrow subject group. A total of seven Army Reserve units, with an average assigned strength of only seventy-two soldiers (there were 504 reservists assigned to the seven units) were evaluated. The GAO’s results are listed as percentages reflecting 90,000 early deployers which may not reflect a valid representative sample. The study does not consider the Army National Guard. Although National Guard policies and procedures were reviewed, National Guard records were not. Any comment about Army Reserve Component readiness involves both the Army Reserve and the Army National Guard. The Army National Guard may not have a problem with any of the readiness areas documented in the Army Reserve, but they were attributed to the National Guard as well. * It is important to clarify the relationship between physical examinations and deployability. There are many factors relating to deployability, which are not included, or may not be addressed, through a physical examination process. * All Reserve Component personnel need an annual health certification and dental screening. The study addresses only early deployers. * The report took a “yes” or “no” approach to meeting the statute’s requirements. It did not indicate if the units were meeting the requirement with alternate systems. The statutory requirement for every member of the Ready Reserve to annually certify their physical condition is defined in AR 40-501, and is to be accomplished using DA Form 7349. However, Troop Program Units (TPUs) within the Army Reserve often do not utilize this form. Instead, Army Reserve TPU soldiers may authenticate a statement of physical condition that is pre-printed on the Personnel Qualification Record, DA Form 2A (officer), 2B (warrant), or 2C (enlisted). The GAO report conveys that none of the records reviewed contained an executed DA Form 7349. The report does not address whether personnel records were reviewed for completion of an alternative. My primary action officer is Colonel John Gardner, at 703-578-8524. Sincerely, Signed by E. P. Wyatt for William Winkenwerder, Jr., MD Enclosure: As stated: GAO Draft Report Dated February 28, 2003 GAO-03-437 (GAO CODE 290179): “DEFENSE HEALTH CARE: ARMY NEEDS TO ASSESS THE HEALTH STATUS OF ALL EARLY DEPLOYING RESERVISTS”: DEPARTMENT OF DEFENSE COMMENTS TO THE GAO RECOMMENDATIONS: RECOMMENDATION 1: The GAO recommended that the Secretary of Defense direct the Secretary of the Army to comply with existing statutory requirements to ensure that the biennial physical examinations for early deploying reservists over 40 and the 5-year physical examinations for early deploying reservists under 40 are current and complete. (p. 21/GAO Draft Report): DOD RESPONSE: Concur with the GAO recommendation. Congress established statutory requirements for biennial and 5-year physical examinations. Using Operation and Maintenance (O&M) dollars allocated from the Department of the Army, the Army Reserve initiated contractual arrangements so those statutory requirements for physical examinations for reserve personnel will be met. The Federal Strategic Health Alliance (FEDS_HEAL) is a VA-HHS-DoD partnership that links the resources of the Veterans Health Administration (VHA) and the Department of Health and Human Services Division of Federal Occupational Health (FOH) to provide immunizations, physical examinations, dental screening and other services to members of the Reserve Components. The fielding of MEDPROS, a component of the Medical Occupational Database System (MODS) provides a web-based system that documents and monitors medical and dental readiness. These programs will serve to improve the medical and dental readiness of the Army reserve components. RECOMMENDATION 2: The GAO recommended that the Secretary of Defense direct the Secretary of the Army to comply with existing statutory requirements to ensure that all early deploying reservists complete their annual medical certificate of health status and that the appropriate Army personnel review the certificate. (p. 21/GAO Draft Report): DOD RESPONSE: Concur with the GAO recommendation. Increasing early deployment units’ readiness does not necessarily follow the pattern of mobilization that occurred during ONE/OEF. All units in the Selected Reserves (SELRES) and the Army Reserve National Guard (ARNG) are subject to mobilization and deployment based on the mission and the needs of the Army, not just a specific operation scenario. Resources and emphasis should be the same for the entire SELRES and the: ARNG. The Army Reserve has developed the Annual Health Certification Questionnaire; a web based program, which will provide a longitudinal file on the health status of all individual reservists. This program is currently in beta testing and will provide thorough health status monitoring of both early deployers and drilling reservists. RECOMMENDATION 3: The GAO recommended that the Secretary of Defense direct the Secretary of the Army to comply with existing statutory requirements to ensure that the required dental examinations and treatments for all early deploying reservists are complete. (p. 21/GAO Draft Report): DOD RESPONSE: Concur with the GAO recommendation. Dental assessment is currently being accomplished through the FEDS_HEAL program, with both private and public agencies and resources. Since the study’s conclusion, the Army has significantly increased its emphasis and efforts to use automated tracking of all medical and dental readiness through MEDPROS. Increased marketing and education about the availability of the reserve dental plan to reservists should improve its utilization and therefore increase dental readiness. [End of section] Appendix V: GAO Contact and Staff Acknowledgments: GAO Contact: Michael T. Blair, Jr., (404) 679-1944: Acknowledgments: The following staff members made key contributions to this report: Aditi S. Archer, Richard J. Wade, Krister P. Friday, Helen T. Desaulniers, and Mary W. Reich. [End of section] Related GAO Products: Military Personnel: Preliminary Observations Related to Income, Benefits, and Employer Support for Reservists During Mobilizations. GAO-03-549T. Washington, D.C.: March 19, 2003. Defense Health Care: Most Reservists Have Civilian Health Coverage but More Assistance Is Needed When TRICARE Is Used. GAO-02-829. Washington, D.C.: September 6, 2002. Reserve Forces: DOD Actions Needed to Better Manage Relations between Reservists and Their Employers. GAO-02-608. Washington, D.C.: June 13, 2002. Department of Defense: Implications of Financial Management Issues. GAO/T-AIMD/NSIAD-00-264. Washington, D.C.: July 20, 2000. Reserve Forces: Cost, Funding, and Use of Army Reserve Components in Peacekeeping Operations. GAO/NSAID-98-190R. Washington, D.C.: May 15, 1998. Defense Health Program: Future Costs Are Likely to Be Greater than Estimated. GAO/NSIAD-97-83BR. Washington, D.C.: February 21, 1997. Wartime Medical Care: DOD Is Addressing Capability Shortfalls, but Challenges Remain. GAO/NSIAD-96-224. Washington, D.C.: September 25, 1996. Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet Medical and Physical Fitness Standards. GAO/NSIAD-94-36. Washington, D.C.: March 23, 1994. Operation Desert Storm: Problems With Air Force Medical Readiness. GAO/ NSIAD-94-58. Washington, D.C.: December 30, 1993. Reserve Components: Factors Related to Personnel Attrition in the Selected Reserve. GAO/NSIAD-91-135. Washington, D.C.: April 8, 1991. [End of section] FOOTNOTES [1] The Army reserve components consist of the U.S. Army Reserve and the Army National Guard. The Army National Guard component carries out a dual mission. It is responsive both to the federal government for national security missions and to governors for state missions. [2] To support its mission needs and war plans the Army has established Force Support Packages 1 and 2--a group of reservists who would normally be the first to be deployed in a ground conflict. In this report we refer to these reservists as early-deploying reservists. [3] Mobilization is the process by which the armed forces are brought into a state of readiness for war or national emergency or to support some other operational mission. In this report, mobilization means calling up reserve components for active duty. Deployment involves the relocation of mobilized forces and materiel to desired areas of operation. [4] 10 U.S.C. §1074a(d)(1)(C) requires the Army to provide early- deploying reservists with a dental screening. While a dental screening does not have to be performed by a dentist, the Army requires its early-deploying reservists to be examined by a dentist to fulfill the screening requirement. Therefore, in this report we use the term “examination” rather than “screening.” [5] Report To Congress: Means of Improving the Provision of Uniform and Consistent Medical and Dental Care to Members of the Reserve Components (Washington, D.C.: October 1999). [6] The number of reservists mobilized changes on a continuous basis as certain reservists are released and others are called-up, as mission needs change. [7] 10 U.S.C. §10206(a)(1)(2000). [8] 10 U.S.C. §10206(a)(2)(2000). [9] 10 U.S.C. §1074a(d)(1)(B)(2000). [10] 10 U.S.C. §1074a(d)(1)(A)(2000). [11] 10 U.S.C. §1074a(d)(1)(C)(2000). [12] 10 U.S.C. §1074a(d)(1)(D)(2000). [13] Approximately 22,500 early-deploying reservists are over age 40. [14] A permanent rating of P3 or P4 exists when the condition that caused it is not likely to improve. [15] The U.S. Preventive Services Task Force was established by the U.S. Public Health Service in 1984 as an independent panel of experts to review the effectiveness of clinical preventive services--screening tests for early detection of disease, immunizations to prevent infections, and counseling for risk reduction. [16] Guide to Clinical Preventive Services, Second Edition--1996, Report of the U.S. Preventive Services Task Force, HHS Office of Public Health and Science, Office of Disease Prevention and Health Promotion. [17] Report To Congress: Means of Improving the Provision of Uniform and Consistent Medical and Dental Care to Members of the Reserve Components (Washington, D.C.: October 1999). [18] U.S. General Accounting Office, Department of Defense: Implications of Financial Management Issues, GAO/T-AIMD/NSIAD-00-264 (Washington, D.C.: July 20, 2000). [19] The average annual cost does not include allowances for inflation, dental treatment, or specialized laboratory fees such as those for pregnancy, phlebotomy, or tuberculosis. [20] The U.S. Army Medical Command’s: Reserve Component 746 Study, (June 22, 1998), provides no specific number stating only that a “significant number” could not be deployed. [21] This study included reservists from the U.S. Army Reserve but not reservists from the Army National Guard. [22] Twenty-two dental examinations listed early-deploying reservists in class 3 out of 101 current (within 1 year) dental examinations. Additional examinations that were available for our review were either out of date or conducted by nondental personnel. [23] U.S. General Accounting Office, Reserve Forces: Cost, Funding, and Use of Army Reserve Components in Peacekeeping Operations, GAO/ NSAID-98-190R (Washington, D.C.: May 15, 1998). [24] There were 504 early-deploying reservists assigned to the seven units we visited. Medical records for 332 reservists were available for our review. Army administrators told us that the remaining files were in transit, with the reservist, or on file at another location.