oversight

Defense Health Care: Army Has Not Consistently Assessed the Health Status of Early-Deploying Reservists

Published by the Government Accountability Office on 2003-07-09.

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

                            United States General Accounting Office

GAO                         Testimony
                            Before the Subcommittee on Oversight and Investigations,
                            Committee on Veterans’ Affairs, House of Representatives




For Release on Delivery
Expected at 2:00 p.m. EST
Wednesday, July 9, 2003
                            DEFENSE HEALTH CARE
                            Army Has Not Consistently
                            Assessed the Health Status
                            of Early-Deploying
                            Reservists
                            Statement of Marjorie E. Kanof
                            Director, Health Care—Clinical
                              and Military Health Care Issues




GAO-03-997T
                            A
                                                  July 9, 2003


                                                  DEFENSE HEALTH CARE

                                                  Army Has Not Consistently Assessed the
Highlights of GAO-03-997T, a testimony            Health Status of Early-Deploying
before the Subcommittee on Oversight
and Investigations, Committee on                  Reservists
Veterans’ Affairs, House of
Representatives




During the 1990-91 Persian Gulf                   The Army has not consistently carried out the statutory requirements for
War, health problems prevented                    monitoring the health and dental status of its early-deploying reservists. As a
the deployment of a significant                   result, the Army does not have sufficient information to know how many
number of Army reservists. As                     reservists can perform their assigned duties and are ready for deployment.
required by the National Defense                  At reserve units GAO visited, approximately 66 percent of the medical
Authorization Act for Fiscal Year
2002, GAO reported on the Army’s
                                                  records were available for review. At those locations, GAO found that about
efforts to assess the health status               13 percent of the 5-year physical examinations had not been performed,
of its early-deploying reservists                 about 49 percent of early-deploying reservists lacked current dental
(Defense Health Care: Army                        examinations, and none of the annual medical certificates required of
Needs to Assess the Health Status                 reservists were completed by them and reviewed by the units.
of All Early-Deploying Reservists
[GAO-03-437, Apr. 15, 2003]).                     Medical experts recommend periodic physical and dental examinations as an
                                                  effective means of assessing health. Army early-deploying reservists need to
GAO was asked to testify on its                   be healthy to meet the specific demands of their occupations; examinations
findings on the Army’s health                     and other health screenings can be used to identify those who cannot
status assessments efforts and the                perform their assigned duties. Without adequate examinations, the Army
implications of those assessments                 may train, support, and mobilize reservists who are unfit for duty.
for the Department of Veterans
Affairs (VA). Specifically, GAO
was asked to determine if the Army                DOD concurred with GAO’s recommendations to comply with statutory
is collecting and maintaining                     requirements to conduct medical and dental examinations and provide
information on reservists’ health                 dental treatment. VA’s ability to perform its missions to provide medical
and review the value and                          care to veterans and compensate them for their service-connected
advisability of providing                         disabilities could be hampered if the Army’s medical surveillance system
examinations. For its report, GAO                 contains inadequate or incomplete information.
reviewed medical records at seven
Army early-deploying reserve units
to determine the number of
                                                  Site Visit Results for Seven U. S. Army Reserve Units
required examinations that have                                                                     100
been conducted and obtained                       100 Percentage
expert opinion on the value of
periodic examinations.
                                                   80

                                                                                      68

                                                   60

                                                                                                                        49

                                                   40



                                                   20
                                                               13


                                                    0
                                                           Reservists           Reservists        Reservists         Reservists
www.gao.gov/cgi-bin/getrpt?GAO-03-997T.                    without a             without a      without a self-   without a dental
                                                        5-year physical       2-year physical    certification     examination
To view the full testimony statement, including
                                                  Source:GAO analysis of Army data.
the scope and methodology, click on the link
above. For more information, contact
Marjorie E. Kanof at (202) 512-7101.
Mr. Chairman and Members of the Subcommittee:

We are pleased to be here as you discuss health assessments for the men
and women in the armed services. Both the Department of Defense
(DOD) and the Department of Veterans Affairs (VA) need this information
to perform their missions. DOD needs health status information to help
ensure the deployment of healthy forces and the continued fitness of those
forces. VA’s Veterans Benefits Administration (VBA) uses health
information to adjudicate veterans’ claims for disability compensation
related to service-connected injuries or illnesses. In addition, the Veterans
Health Administration (VHA) needs this information to fulfill its mission to
provide health care services to veterans. In this context, you asked us to
discuss our recent report on the Department of the Army’s (Army)
assessment of the health status of its reserve forces. The 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

When reservists were mobilized during the 1990-91 Persian Gulf War, 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.2 In an effort to help ensure that Army reservists meet the
military’s health standards and are ready to perform their assigned duties,
the Congress augmented health assessment requirements that had been in
place prior to the Persian Gulf War. Specifically, the Congress required
the Army to monitor the health status of those designated as early-
deploying reservists3 by providing annual medical screenings, annual
dental screenings, selected dental treatment, and for those over age 40,
physical examinations every 2 years. All reservists, including early
deployers, are also required to disclose annually to the Army the status of


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 to
both the federal government for national security missions and to governors for state
missions.
2
 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.
3
 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. We refer to these reservists as early-deploying reservists.




Page 1                                                                     GAO-03-997T
their physical and dental condition, and those under age 40 are required to
undergo a physical examination once every 5 years.

My testimony today is based on our April 2003 report on the Army’s efforts
to assess the health status of the approximately 90,000 reservists who are
specifically designated as early-deploying reservists.4 We examined
medical records to determine whether the Army is collecting and
maintaining information on the health status of its early-deploying
reservists. We also assessed the value of periodic physical and dental
examinations and determined the advisability of the statutory
requirements for the Army’s early-deploying reservists.

To do our work, 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. 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 examinations5 and to provide dental treatment. We also reviewed
studies and information on the effectiveness of periodic physical and
dental examinations published by DOD, 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. We conducted our work from May 2002 through
April 2003 in accordance with generally accepted government auditing
standards.


4
 U.S. General Accounting Office, Defense Health Care: Army Needs to Assess the Health
Status of All Early-Deploying Reservists, GAO-03-437 (Washington, D.C.: Apr. 15, 2003).
5
 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 requirements. Therefore, in this report we use the term “examination” rather
than “screening.”




Page 2                                                                       GAO-03-997T
             In summary, the Army has not consistently carried out the statutory
             requirements for monitoring the health and dental status of Army early-
             deploying reservists. As a result, the Army does not have sufficient
             information to know how many reservists can perform their assigned
             duties and are ready for deployment. At the seven units we visited,
             approximately 66 percent of the medical records were available for our
             review. 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.
             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. 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. In addition, for reservists who may become eligible
             for VA benefits, inadequate health information can make it more difficult
             to adjudicate claims for service-connected disabilities in an accurate and
             timely manner and to provide quality medical care.

             We made recommendations that the Army comply with existing statutory
             requirements to help ensure that early-deploying reservists are healthy to
             carry out their duties. DOD agreed with our recommendations.


             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



             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.




             Page 3                                                                      GAO-03-997T
    throughout the world in peacekeeping missions. 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
                                            7
    • have a 5-year physical examination, and
    • complete an annual certificate of physical condition.8

•   All early-deploying reservists are also required to have
                                                        9
    • a biennial physical examination if over age 40,
    • an annual medical screening,10
                                    11
    • an annual dental screening, and
                         12
    • dental treatment.




    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).




    Page 4                                                          GAO-03-997T
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. I 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.

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. 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.

Further, 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. Reservists in dental class 3 and 4 are not deployable.


13
 Approximately 22,500 early-deploying reservists are over age 40.




Page 5                                                              GAO-03-997T
                             Class 3 reservists could have dental emergencies in the next 12 months,
                             and reservists in class 4 have not had the required annual dental
                             examination.

                             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 sufficient health
                             information on early-deploying reservists. Furthermore, the Army does
Dental Information on        not have the ability to maintain information from medical and dental
Early-Deploying              records and annual medical certificates at the aggregate or individual
Reservists                   level, and 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. 14 Based on our review of these records, 13 percent of the
Completed and Reviewed       reservists did not have a current 5-year physical examination on file.
                             Further, 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.




                             14
                               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 6                                                                      GAO-03-997T
                         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
                         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 access to current, accurate, and relevant medical and dental
                         information at the aggregate and individual level 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.




                         Page 7                                                          GAO-03-997T
                            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
Are Valuable for            to fulfill their professional responsibilities, periodic examinations are
Assessing Health            useful 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. Such information is also needed by VA to
Army and VA                 adjudicate disability claims and to provide health benefits.


Experts Look to Screening   Physical and dental examinations are geared towards assessing and
and Examinations as Key     improving the overall health of the general population. The U.S.
Indicators of Health        Preventive Services Task Force15 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.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


                            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-03-997T
                      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.17 The report stated that additional
                      research needs to be undertaken to identify and develop a more cost-
                      effective, focused health assessment tool for use in conducting physical
                      exams 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-03-997T
                            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 Federal Strategic Health Care Alliance
                            program (FEDS_HEAL )—an alliance of private physicians and dentists
                            and other physicians and dentists who work for VA 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.

                            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 For   because the average cost to provide physical and dental examinations per
the Army                    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.


                            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-03-997T
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).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




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.



Page 11                                                                      GAO-03-997T
                     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
                     investment because it will train, support, and mobilize reservists who
                     might not be deployed because of their health.


Benefits of Health   Both VBA and VHA need health assessment data obtained by the Army to
Assessments for VA   adjudicate disability claims and provide medial care. In general, a reservist
                     who is disabled while on active duty, or on inactive duty for training, is
                     eligible for service-connected disability compensation, and can file a claim
                     at one of VBA’s 57 regional offices. To provide such disability
                     compensation, VBA needs to determine that each claimed disability exists,
                     and that each was caused or aggravated by the veteran’s military service.
                     The evidence needed to prove service connection includes records of
                     service to identify when the veteran served and records of medical
                     treatment provided while the veteran was in military service. More timely
                     and accurate health information collection by the Army and the other
                     military services can help VBA provide disabled reservists with more
                     timely and accurate decisions on their claims for disability compensation.24
                     Complete and accurate health data can also help VHA provide medical
                     care to reservists who become eligible for veterans benefits.


                     Army reservists have been increasingly called upon to serve in a variety of
Concluding           operations, including peacekeeping missions and the current war on
Observations         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.




                     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
                      See U.S. General Accounting Office, Veterans’ Benefits: Despite Recent Improvements,
                     Meeting Claims Processing Goals Will Be Challenging, GAO-02-645T (Washington, D.C.:
                     April 26, 2002) for a discussion of the information needed to adjudicate a disability claim.




                     Page 12                                                                        GAO-03-997T
                  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 per
                  reservist 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.

                  While our work focused on the Army’s efforts to assess the health status of
                  its early-deploying reservists, it also has implications for veterans.
                  Implementing our recommendations that DOD comply with the statutory
                  requirements, which DOD has agreed to, will also be of benefit to VA. VA’s
                  ability to perform its missions to provide medical care to veterans and
                  compensate them for their service-connected disabilities could be
                  hampered if the Army’s medical surveillance system contains inadequate
                  or incomplete information.

                  Mr. Chairman, this concludes my prepared statement. I will be happy to
                  answer any questions you or other members of the subcommittee may
                  have.


                  For further information regarding this testimony, please contact Marjorie
Contact and       E. Kanof at (202) 512-7101. Michael T. Blair, Jr., Aditi S. Archer, Richard J.
Acknowledgments   Wade, and Gregory D. Whitney also contributed to this statement.




                  Page 13                                                           GAO-03-997T
Appendix I: Army Physical Profile Rating
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,            of motion, and       of movement,      sensitivity and       organic disease     and duration of
                     stamina, agility,    general efficiency   and efficiency of organic disease       of the eyes and     the psychiatric
                     energy, muscular     of upper arm,        feet, legs, lower of the ears.          lids.               symptoms or
                     coordination,        shoulder girdle,     back, and pelvic                                            disorder
                     function, and        and upper back,      girdle.                                                     existing at the
                     similar factors.     including cervical                                                               time the profile
                                          and thoracic                                                                     is determined.
                                          vertebrae.                                                                       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.
P1                   Good muscular        No loss of digits    No loss of digits   Audiometer          Uncorrected         No psychiatric
(Non-duty-limiting   development with     or limitation of     or limitation of    average level for   vision acuity       pathology; may
conditions)          ability to perform   motion; no           motion; no          each ear not        20/200              have history of
                     maximum effort       demonstrable         demonstrable        more than 25 dBa    correctable to      transient
                     for indefinite       abnormality; able    abnormality; able   at 500, 1000, or    20/20 in each       personality
                                                                                            b
                     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.




                                             Page 14                                                                        GAO-03-997T
                                                                               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
 (Non-duty-limiting           maximum effort     mobility of joints,  mobility of joints, average level for             acuity correctable   history of
 conditions)                  over long          muscular             muscular            each ear at 500,              to not worse than    recovery from
                              periods.           weakness, or         weakness, or        1000, or 2000                 20/40 and 20/70,     an acute
                                                 other musculo-       other musculo-      Hz, not more                  or 20/30 and         psychotic
                                                 skeletal defects     skeletal defects    than 30 dB, with              20/100, or 20/20     reaction due to
                                                 that do not          that do not         no individual                 and 20/400.          external or
                                                 prevent hand-to-     prevent moderate level greater than                                    toxic causes
                                                 hand fighting and    marching,           35 dB at these                                     unrelated to
                                                 do not disqualify    climbing, timed     frequencies, and                                   alcohol or drug
                                                 for prolonged        walking, or         level not more                                     addiction.
                                                 effort.              prolonged effort. 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.)
 P3                           Unable to           Defects or          Defects or          Speech reception              Uncorrected          Satisfactory
 (Duty-limiting               perform full effort impairments that impairments that threshold in best                   distant visual       remission from
 conditions)                  except for brief or require significant require significant ear not greater               acuity of any        an acute
                              moderate            restriction of use. restriction of use. than 30 dB HLc                degree that is       psychotic or
                              periods.                                                    measured with or              correctable to not   neurotic
                                                                                          without hearing               less than 20/40 in   episode that
                                                                                          aid, or chronic               the better eye.      permits
                                                                                          ear disease.                                       utilization
                                                                                                                                             under specific
                                                                                                                                             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
 (Duty-limiting               below P3.          below P3.                below P3.              below P3.              below P3.            level below P3.
 conditions)

Source: Department of the Army.

                                                     Note: Army Regulation 40-501, Mar. 28, 2002.
                                                     a
                                                         dB (decibels), the decibel is a measure of the intensity of sound.
                                                     b
                                                         Hz (Hertz), the Hertz is the measure of sound frequency or pitch.
                                                     c
                                                         HL (hearing loss).




                                                     Page 15                                                                                  GAO-03-997T
Related GAO Products


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             Early-Deploying Reservists. GAO-03-347. Washington, D.C.: April 15, 2003.

             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.

             Veterans’ Benefits: Despite Recent Improvements, Meeting Claims
             Processing Goals Will Be Challenging. GAO-02-645T. Washington, D.C.:
             April 26, 2002.

             VA and Defense Health Care: Military Medical Surveillance Policies in
             Place, But Implementation Challenges Remain. GAO-02-478T.
             Washington, D.C.: February 27, 2002.

             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-03-549T. Washington, D.C.: December 30, 1993.

             Defense Health Care: Physical Exams and Dental Care Following the
             Persian Gulf War. GAO/HRD-93-5. Washington, D.C.: October 15, 1992.


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             Page 16                                                      GAO-03-997T
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