oversight

Defense Health Care: Army Needs to Assess the Health Status of All Early-Deploying Reservists

Published by the Government Accountability Office on 2003-04-15.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States General Accounting Office

GAO          Report to Congressional Committees




April 2003
             DEFENSE HEALTH
             CARE
             Army Needs to Assess
             the Health Status of
             All Early-Deploying
             Reservists




GAO-03-437
                                               April 2003


                                               DEFENSE HEALTH CARE

                                               Army Needs to Assess the Health Status
Highlights of GAO-03-437, a report to
Congressional Committees                       of All Early-Deploying Reservists



During the 1990-1991 Persian Gulf              Medical experts recommend periodic physical and dental examinations as an
War, health problems prevented                 effective means of assessing health. Periodic physical and dental
the deployment of a significant                examinations for early-deploying reservists provide a means for the Army to
number of Army reservists. To                  determine their health status. Army early-deploying reservists need to be
help correct this problem the                  healthy to meet the specific demands of their occupations; examinations and
Congress passed legislation that
required reservists to undergo
                                               other health screenings can be used to identify those who cannot perform
periodic physical and dental                   their assigned duties. Without adequate examinations, the Army may train,
examinations. The National                     support, and mobilize reservists who are unfit for duty.
Defense Authorization Act for 2002
directed GAO to review the value               The Army has not consistently carried out the statutory requirements for
and advisability of providing                  monitoring the health and dental status of Army early-deploying reservists.
examinations. GAO also examined                At the early-deploying units GAO visited, approximately 66 percent of the
whether the Army is collecting and             medical records were available for review. For example, we found that
maintaining information on                     about 68 percent of the required 2-year physical examinations for those over
reservist health. GAO obtained                 age 40 had not been performed and that none of the annual medical
expert opinion on the value of
periodic examinations and visited
                                               certificates required of reservists were completed by reservists and
seven Army reserve units to obtain             reviewed by the units.
information on the number of
examinations that have been                    The Army’s automated health care information system does not contain
conducted.                                     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.
GAO recommends that the
Secretary of Defense ensure that               Site Visit Results for Seven U. S. Army Reserve Units
for early-deploying reservists                                                                   100
                                               100 Percentage
•    5-year physical examinations
     for those under 40 and 2-year
     physical examinations for                  80
     those over 40 are complete;                                                   68
•    annual medical certificates are
     complete and that they are                 60
     reviewed by the Army; and                                                                                       49
•    annual dental examinations
     and needed treatments are                  40

     complete.
                                                20
DOD concurred with the                                      13
recommendations.
                                                 0
                                                        Reservists           Reservists        Reservists         Reservists
                                                        without a             without a      without a self-   without a dental
                                                     5-year physical       2-year physical    certification     examination
www.gao.gov/cgi-bin/getrpt?GAO-03-437.         Source:GAO analysis of Army data.

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.
Contents


Letter                                                                                                1
                       Results in Brief                                                               3
                       Background                                                                     4
                       Periodic Physical and Dental Examinations Are Valuable for
                         Assessing Health Status and Provide Beneficial Information to
                         the Army                                                                     8
                       The Army Has Not Collected and Maintained All Required Medical
                         and Dental Information on Early-Deploying Reservists                       12
                       Conclusions                                                                  13
                       Recommendations for Executive Action                                         14
                       Agency Comments and Our Evaluation                                           15

Appendix I             Scope and Methodology                                                        18



Appendix II            Army Physical Profile Rating Guide                                           19



Appendix III           Annual Medical Certificate                                                   21



Appendix IV            Comments from the Department of Defense                                      23



Appendix V             GAO Contact and Staff Acknowledgments                                        27
                       GAO Contact                                                                  27
                       Acknowledgments                                                              27

Related GAO Products                                                                                28



Table
                       Table 1: DOD Dental Classifications and Their Description                      7




                       Page i                     GAO-03-437 Assessing Health Status of Army Reservists
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




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Page ii                           GAO-03-437 Assessing Health Status of Army Reservists
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.1 Of these reservists,
                                   approximately 90,000 are specifically designated as early-deploying
                                   reservists.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.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


                                   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.



                                   Page 1                             GAO-03-437 Assessing Health Status of Army Reservists
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 Army’s 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
examinations4 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. 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


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).




Page 2                            GAO-03-437 Assessing Health Status of Army Reservists
                   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.


                   Periodic physical and dental examinations for early-deploying reservists
Results in Brief   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.




                   Page 3                      GAO-03-437 Assessing Health Status of Army Reservists
                 In recent years, reservists have regularly been called on to augment the
Background       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 reservists6
                 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,7 and
                                                                          8
                 • complete an annual certificate of physical condition.




                 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).




                 Page 4                            GAO-03-437 Assessing Health Status of Army Reservists
•   All early-deploying reservists are also required to have
                                                        9
    • a biennial physical examination if over age 40,
                                       10
    • an annual medical screening,
                                    11
    • an annual dental screening, and
                         12
    • dental treatment.

    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 4013 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.




    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.




    Page 5                                 GAO-03-437 Assessing Health Status of Army Reservists
Beginning in January 2003, early-deploying reservists with a permanent
rating of P3 or P414 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.)




14
 A permanent rating of P3 or P4 exists when the condition that caused it is not likely to
improve.




Page 6                             GAO-03-437 Assessing Health Status of Army Reservists
Table 1: DOD Dental Classifications and Their Description

 Class 1                 Class 2                  Class 3                   Class 4
 reservist is            reservist is             reservist is              reservist is
 deployable              deployable               nondeployable             nondeployable
 Reservists not          Reservists who have      Reservists who have       Reservists who
 requiring dental        oral conditions that,    oral conditions that if   have not had the
 treatment or            if not treated or        not treated are           required annual
 reevaluation within     followed up, have        expected to result in     dental examination.
 12 months.              the potential but are    dental emergencies
                         not expected to          within 12 months.
                         result in dental         Reservists should be
                         emergencies within       placed in Class 3
                         12 months.               when there are
                                                  questions in
                                                  determining
                                                  classification
                                                  between Class 2
                                                  and Class 3.

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).


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.




Page 7                              GAO-03-437 Assessing Health Status of Army Reservists
                        Medical experts recommend physical and dental examinations as an
Periodic Physical and   effective means of assessing health. For some people, the frequency and
Dental Examinations     content of physical examinations vary according to the specific demands
                        of their job. Because Army early-deploying reservists need to be healthy to
Are Valuable for        fulfill their professional responsibilities, periodic examinations are useful
Assessing Health        for assessing whether they can perform their assigned duties.
                        Furthermore, the estimated annual cost to conduct periodic
Status and Provide      examinations—about $140—is relatively modest compared to the
Beneficial              thousands of dollars the Army spends for salaries and training of early-
Information to the      deploying reservists—an investment that may be lost if reservists can not
                        perform their assigned duties.
Army
Experts Look to         Physical and dental examinations are geared towards assessing and
Screenings and          improving the overall health of the general population. The U.S. Preventive
Examinations as Key     Services Task Force15 and many other medical organizations no longer
                        recommend annual physical examinations for adults—preferring instead a
Indicators of Health    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.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


                        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.




                        Page 8                             GAO-03-437 Assessing Health Status of Army Reservists
                      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.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    For its early-deploying reservists, the Army conducts and pays for physical
Physical and Dental   and dental examinations and selected dental treatments at military
Examinations and      treatment facilities or pays civilian physicians and dentists to provide
                      these services. The Army could not provide us with information on the
Providing Dental      cost to provide these services at military hospitals or clinics primarily
Treatments            because it does not have a cost accounting system that records or




                      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).




                      Page 9                         GAO-03-437 Assessing Health Status of Army Reservists
                         generates cost data for each patient.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.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   For the Army, there is likely value in conducting periodic examinations
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.




                         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.




                         Page 10                           GAO-03-437 Assessing Health Status of Army Reservists
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).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.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 3.22 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 $800.23 If it does not
examine all of its early-deploying reservists, the Army risks losing its




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).




Page 11                           GAO-03-437 Assessing Health Status of Army Reservists
                             investment because it will train, support, and mobilize reservists who
                             might not be deployed because of their health.


                             The Army has not consistently carried out the requirements that early-
The Army Has Not             deploying reservists undergo 5- or 2-year physical examinations, and the
Collected and                required dental examination. In addition, the Army has not required early-
                             deploying reservists to complete the annual medical certificate of their
Maintained All               health condition, which provides the basis for the required annual medical
Required Medical and         screening. Accordingly, the Army does not have current health information
                             on early-deploying reservists. Furthermore, the Army does not have the
Dental Information on        ability to maintain information from medical and dental records and
Early-Deploying              annual medical certificates at the aggregate or individual level, and
Reservists                   therefore does not know the overall health status of its early-deploying
                             reservists.


Examinations Have Not        We found that the Army has not consistently met the statutory
Always Been Performed        requirements to provide early-deploying reservists physical examinations
and Annual Medical           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
Certificates Have Not Been   review.24 Based on our review of these records, 13 percent of the reservists
Completed and Reviewed       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




                             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.




                             Page 12                           GAO-03-437 Assessing Health Status of Army Reservists
                         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         The Army’s two automated information systems for monitoring reservists’
Systems Do Not Contain   health do not maintain important medical and dental information for early-
Comprehensive Health     deploying reservists—including information on the early-deploying
                         reservists’ overall health status, information from the annual medical
Information on Early-    certificate form, dental classifications, and the date of dental
Deploying Reservists     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.


                         Army reservists have been increasingly called upon to serve in a variety of
Conclusions              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-


                         Page 13                      GAO-03-437 Assessing Health Status of Army Reservists
                      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.


                      To help ensure that early-deploying reservists are healthy to carry out their
Recommendations for   duties, we recommend that the Secretary of Defense direct the Secretary
Executive Action      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.




                      Page 14                     GAO-03-437 Assessing Health Status of Army Reservists
                     The Department of Defense provided written comments on a draft of this
Agency Comments      report, which are found in appendix IV. DOD concurred with the report’s
and Our Evaluation   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




                     Page 15                     GAO-03-437 Assessing Health Status of Army Reservists
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




Page 16                    GAO-03-437 Assessing Health Status of Army Reservists
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




Page 17                   GAO-03-437 Assessing Health Status of Army Reservists
             Appendix I: Scope and Methodology
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.




             Page 18                         GAO-03-437 Assessing Health Status of Army Reservists
                                           Appendix II: Army Physical Profile Rating
Appendix II: Army Physical Profile Rating  Guide



Guide


                                                                    Assessment areas
Physical profile Physical             Upper                Lower
rating           capacity             extremities          extremities       Hearing-ears          Vision-eyes         Psychiatric
                 Organic defects,     Strength, range      Strength, range   Auditory              Visual acuity and   Type, severity,
                 strength, stamina,   of motion, and       of movement,      sensitivity and       organic disease     and duration of
                 agility, energy,     general              and efficiency of organic disease       of the eyes and     the psychiatric
                 muscular             efficiency of        feet, legs, lower of the ears.          lids.               symptoms or
                 coordination,        upper arm,           back, and pelvic                                            disorder existing
                 function, and        shoulder girdle,     girdle.                                                     at the time the
                 similar factors.     and upper back,                                                                  profile is
                                      including cervical                                                               determined.
                                      and thoracic                                                                     Amount of
                                      vertebrae.                                                                       external
                                                                                                                       precipitating
                                                                                                                       stress.
                                                                                                                       Predispositions
                                                                                                                       as determined by
                                                                                                                       the basic
                                                                                                                       personality
                                                                                                                       makeup,
                                                                                                                       intelligence,
                                                                                                                       performance,
                                                                                                                       and history of
                                                                                                                       past psychiatric
                                                                                                                       disorder
                                                                                                                       impairment of
                                                                                                                       functional
                                                                                                                       capacity.
P1               Good muscular        No loss of digits    No loss of digits   Audiometer          Uncorrected         No psychiatric
(Non-duty-       development with     or limitation of     or limitation of    average level for   vision acuity       pathology; may
limiting         ability to perform   motion; no           motion; no          each ear not        20/200              have history of
conditions)      maximum effort       demonstrable         demonstrable        more than 25 dB1    correctable to      transient
                 for indefinite       abnormality; able    abnormality; able   at 500, 1000, or    20/20 in each       personality
                                                                                        2
                 periods.             to do hand-to-       to perform long     2000 Hz with no     eye.                disorder.
                                      hand fighting.       marches, stand      individual level
                                                           over long           greater than 30
                                                           periods, and run.   dB. Not over 45
                                                                               dB at 4000 Hz.




                                           1
                                            dB (decibels), the decibel is a measure of the intensity of sound.
                                           2
                                            Hz (Hertz), the Hertz is the measure of sound frequency or pitch.




                                           Page 19                             GAO-03-437 Assessing Health Status of Army Reservists
                                              Appendix II: Army Physical Profile Rating
                                              Guide




                                                                      Assessment areas
 Physical profile   Physical             Upper              Lower
 rating             capacity             extremities        extremities         Hearing-ears         Vision-eyes          Psychiatric
 P2                 Able to perform      Slightly limited   Slightly limited    Audiometer           Distant visual       May have history
 (Non-duty-         maximum effort       mobility of joints,mobility of joints, average level for    acuity               of recovery from
 limiting           over long periods.   muscular           muscular            each ear at 500,     correctable to not   an acute
 conditions)                             weakness, or       weakness, or        1000, or 2000        worse than 20/40     psychotic
                                         other musculo-     other musculo-      Hz, not more         and 20/70, or        reaction due to
                                         skeletal defects   skeletal defects    than 30 dB, with     20/30 and            external or toxic
                                         that do not        that do not         no individual        20/100, or 20/20     causes unrelated
                                         prevent hand-to-   prevent             level greater than   and 20/400.          to alcohol or drug
                                         hand fighting and  moderate            35 dB at these                            addiction.
                                         do not disqualify  marching,           frequencies, and
                                         for prolonged      climbing, timed     level not more
                                         effort.            walking, or         than 55 dB at
                                                            prolonged effort. 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.)
 P3                 Unable to           Defects or          Defects or          Speech               Uncorrected          Satisfactory
 (Duty-limiting     perform full effort impairments that impairments that reception                  distant visual       remission from
 conditions)        except for brief or require             require             threshold in best    acuity of any        an acute
                    moderate            significant         significant         ear not greater      degree that is       psychotic or
                    periods.            restriction of use. restriction of use. than 30 dB HL3       correctable to not   neurotic episode
                                                                                measured with or     less than 20/40      that permits
                                                                                without hearing      in the better eye.   utilization under
                                                                                aid, or chronic                           specific
                                                                                ear disease.                              conditions
                                                                                                                          (assignment
                                                                                                                          when outpatient
                                                                                                                          psychiatric
                                                                                                                          treatment is
                                                                                                                          available or
                                                                                                                          certain duties
                                                                                                                          can be avoided).
 P4                 Functional level     Functional level      Functional level   Functional level   Functional level     Functional level
 (Duty-limiting     below P3.            below P3.             below P3.          below P3.          below P3.            below P3.
 conditions)

Source: Army.

                                              Note: Army Regulation 40-501, Mar. 28, 2002.




                                              3
                                               HL (hearing loss).




                                              Page 20                             GAO-03-437 Assessing Health Status of Army Reservists
               Appendix III: Annual Medical Certificate
Appendix III: Annual Medical Certificate




               Page 21                           GAO-03-437 Assessing Health Status of Army Reservists
Appendix III: Annual Medical Certificate




Page 22                           GAO-03-437 Assessing Health Status of Army Reservists
             Appendix IV: Comments from the Department
Appendix IV: Comments from the
             of Defense



Department of Defense




             Page 23                        GAO-03-437 Assessing Health Status of Army Reservists
Appendix IV: Comments from the Department
of Defense




Page 24                        GAO-03-437 Assessing Health Status of Army Reservists
Appendix IV: Comments from the Department
of Defense




Page 25                        GAO-03-437 Assessing Health Status of Army Reservists
Appendix IV: Comments from the Department
of Defense




Page 26                        GAO-03-437 Assessing Health Status of Army Reservists
                  Appendix V: GAO Contact and Staff
Appendix V: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Michael T. Blair, Jr., (404) 679-1944
GAO Contact
                  The following staff members made key contributions to this report: Aditi
Acknowledgments   S. Archer, Richard J. Wade, Krister P. Friday, Helen T. Desaulniers, and
                  Mary W. Reich.




                  Page 27                         GAO-03-437 Assessing Health Status of Army Reservists
             Related GAO Products
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.




(290179)
             Page 28                    GAO-03-437 Assessing Health Status of Army Reservists
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