```
                                                                 
Defense Health Care: Health Care Benefit for Women Comparable to 
Other Plans (01-MAY-02, GAO-02-602).				 
                                                                 
Half of all beneficiaries in the Department of Defense's (DOD)	 
Tricare health care program are women. With a health care system 
historically oriented towards men, DOD has had to work to ensure 
that its women beneficiaries receive the full range of medical	 
services they are entitled to, including obstetrical and	 
gynecological care and diagnostic services such as Pap smears and
mammograms. TRICARE-covered benefits are in line with American	 
College of Obstetricians and Gynecologists guidelines and are	 
comparable to women's health benefits offered by two of the	 
largest health plans under the Federal Employees Health Benefits 
Program (FEHBP). DOD also requires some beneficiaries to share in
the cost of their health care. Both DOD's and FEHBP's copayments,
which are the same for men and women, vary depending on the plan 
option and the providers selected. Women beneficiaries report	 
being satisfied with the health care benefits they receive under 
TRICARE. Some women beneficiaries, however, have expressed	 
concerns about obtaining services when they are stationed	 
overseas or in remote areas. Some active duty women are also	 
concerned that command personnel may not understand women's	 
health care needs.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-602 					        
    ACCNO:   A03210						        
  TITLE:     Defense Health Care: Health Care Benefit for Women       
Comparable to Other Plans					 
     DATE:   05/01/2002 
  SUBJECT:   Beneficiaries					 
	     Comparative analysis				 
	     Health care programs				 
	     Health care services				 
	     Military dependents				 
	     Military personnel 				 
	     Retired military personnel 			 
	     Women						 
	     DOD TRICARE Extra Program				 
	     DOD TRICARE Prime Program				 
	     DOD TRICARE Program				 
	     Federal Employees Health Benefits			 
	     Program						 
                                                                 

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GAO-02-602
     
A

Report to Congressional Committees

May 2002 DEFENSE HEALTH CARE Health Care Benefit for Women Comparable to
Other Plans

GAO- 02- 602

Letter 1 Results in Brief 2 Background 3 DOD?s Health Care Benefit for Women
is Comparable to Other

Plans 6 Most Women Beneficiaries Are Satisfied With DOD?s Health Care

Benefit, but Some Concerns Exist 10 Concluding Observations 15 Agency
Comments 15

Appendix I: Scope and Methodology 18

Appendix II: DOD Policies And Initiatives To Improve Women?s Health Care 20
DOD- wide Policies and Initiatives 20 Specific Initiatives by Each Branch of
Service 22

Appendix III: Comments from the Department of Defense 27

Appendix IV: GAO Contacts and Staff Acknowledgments 28 GAO Contacts 28 Staff
Acknowledgments 28

Tables Table 1: Comparison of TRICARE Pap Smear and Mammogram Standards With
ACOG Guidelines and Other Plan

Standards 8 Table 2: Women Beneficiaries? Responses to Measures of

Satisfaction Compared to Men?s 11 Figure Figure 1: Men and Women Active Duty
and Nonactive Duty

Beneficiaries by Branch of the Military, as of April 1, 2002 4

Abbreviations

ACOG American College of Obstetricians and Gynecologists CHPPM Center for
Health Promotion and Preventive Medicine DACOWITS Defense Advisory Committee
on Women in the Services DES diethylstilbestrol DOD Department of Defense
FEHBP Federal Employees Health Benefits Program HMO health maintenance
organization MTF military treatment facility NDAA National Defense
Authorization Act NMFA National Military Family Association PCM primary care
manager REACH Recruit Education to Achieve Health SHARP Sexual Health and
Responsibility Program TMA TRICARE Management Activity TPR TRICARE Prime
Remote

Letter

May 1, 2002 Congressional Committees About half of all beneficiaries who are
eligible to use TRICARE, the Department of Defense?s (DOD) health care
program, are women- either active duty personnel, family members, or
retirees. With a health care system historically oriented towards men, DOD
has been challenged to ensure that its women beneficiaries receive the full
range of services including primary, specialty, preventive, and reproductive
care. The

National Defense Authorization Act (NDAA) for fiscal year 2002 directed that
we study the adequacy and quality of the health care provided to women by
DOD. As agreed with the committees of jurisdiction, we will describe (1) the
health care benefit targeted to women covered under the TRICARE program and
how this benefit compares to national clinical guidelines and other health
plans? offerings and (2) women beneficiaries? satisfaction with and concerns
about DOD?s health care benefit.

To conduct our work, we reviewed relevant policies and procedures and
interviewed officials from DOD?s Health Affairs? Office of Clinical and
Program Policy; DOD?s TRICARE Management Activity (TMA); and the Surgeons
General Offices for the Air Force, Army, and Navy. We also interviewed
officials from the American College of Obstetricians and Gynecologists
(ACOG) 1 and reviewed two of the largest health care plans under the Federal
Employees Health Benefits Program (FEHBP) 2 to compare the covered benefits
with TRICARE?s. To determine beneficiaries? perceptions on women?s health
care services in TRICARE, we relied on our past work on DOD health care, and
we reviewed the latest available data from two DOD surveys: a DOD- wide
health care survey on beneficiary satisfaction and a survey targeted at
inpatient care during childbirth at selected military treatment facilities
(MTF). In addition, we held interviews with the Defense Advisory Committee
on Women in the Services (DACOWITS), a group that advises the Secretary of
Defense on issues concerning active duty women, and the National Military
Family

1 ACOG is a national organization that develops guidelines for clinical
practice for women?s health care services. 2 The FEHBP, administered by the
Office of Personnel Management, is the largest employersponsored group
health insurance program in the world. FEHBP offers fee- for- service plans
with preferred provider organizations, health maintenance organization (HMO)
plans, and plans offering a point- of- service product.

Association (NMFA), an advocacy group that obtains beneficiary views on
issues concerning military families. However, we did not independently
validate this information or determine the prevalence of beneficiary
concerns. It should also be noted that while our review focuses on health
care for women beneficiaries, a number of our findings pertain to men as
well, which we note where appropriate. Our work was conducted from November
2001 through April 2002 in accordance with generally accepted government
auditing standards. (For more on our scope and methodology, see app. I.)

Results in Brief TRICARE offers a full range of health care services for
women beneficiaries, including obstetrical and gynecological care and
diagnostic

services such as Papanicolaou (Pap) smears and mammograms. The TRICARE
benefits package is uniform across all three branches of the military and
for all beneficiary types- active duty personnel, family members, and
retirees. The TRICARE covered benefits are in line with ACOG guidelines and
are comparable to women?s health benefits offered by two of the largest
health plans under FEHBP. In addition, DOD- like the FEHBP plans we
reviewed- requires some beneficiaries to share in the cost of their health
care. Both DOD?s and FEHBP?s copayments, which are

the same for men and women, vary depending on the plan option and providers
selected. 3 DOD?s women beneficiaries, overall, report being satisfied with
the health care benefit they receive under TRICARE. For example, the average
rating from women for the health care they received was 7. 8 on a scale
where 10 represents the best health care possible- the same rating as given
by men. Some of DOD?s women beneficiaries, however, have expressed concerns
about obtaining the services available to them. Generally, these concerns
stem from where the beneficiary is located- especially those stationed
overseas or in remote areas- and beneficiaries? expectations about the
providers, sources of care, and supplies available to them. For example, in
overseas locations, DOD beneficiaries may face medical practice, language,
and cultural differences with host nation care that can make them reluctant
to seek care. DOD officials told us that for active duty women, concerns
also stem from the attitudes and the climate established by the command
personnel who may not understand women?s health care needs. DOD

3 Active duty personnel and their family members who are enrolled in TRICARE
Prime- DOD?s HMO option- do not have copayments.

officials also told us that some commanders may be reluctant to allow active
duty members- both men and women- time away from their duty stations to
obtain health care services. In commenting on a draft of our report, DOD
agreed with our findings.

Background DOD?s medical mission includes maintaining the health of 1.7
million active duty personnel 4 and providing health care to them during
military

operations. About 12 percent of the Navy?s active duty personnel, 5 about 16
percent of the Army?s active duty personnel, and about 19 percent of the Air
Force?s active duty personnel are women. DOD also offers health care to
women who are family members of active duty personnel, retirees, family
members of retirees, and survivors of active duty and retired active duty
members (see fig. 1).

4 Includes members of the Coast Guard, the Commissioned Corps of the
National Oceanic and Atmospheric Administration and of the Public Health
Service. It also includes National Guard members who are eligible for care
in the military health system when they are in active duty status.

5 The calculation of the percent of women active duty personnel in the Navy
includes active duty personnel in the Marine Corps.

Figure 1: Men and Women Active Duty and Nonactive Duty Beneficiaries by
Branch of the Military, as of April 1, 2002 1,400,000

Beneficiaries 1,200,000 1,000,000

800,000 600,000 400,000 200,000

0 Navy a Army Air Force

Active duty women Active duty men Nonactive duty women b Nonactive duty men
b

a The number of Navy beneficiaries includes beneficiaries in the Marine
Corps. b Nonactive duty beneficiaries include family members of active duty
personnel, retirees, family members of retirees, and survivors of active
duty and retired active duty members. Source: DOD.

DOD beneficiaries are provided benefits through one of three health plans:
TRICARE Prime (an HMO option), TRICARE Extra (a preferred provider option),
and TRICARE Standard (a fee- for- service option). Active duty members are
required to enroll in TRICARE Prime, but family members and retirees under
age 65 can choose among any of the three plans. DOD

also provides benefits to military beneficiaries who are Medicare- eligible.
6 Beneficiary copayments vary depending on the TRICARE option. Active duty
personnel and their family members who are enrolled in TRICARE Prime do not
have copayments.

Under TRICARE, health care is provided in MTFs worldwide and by civilian
providers. Priority for care at MTFs varies depending on the beneficiary
type- active duty, family member, or retiree- and the TRICARE option. Active
duty members have the highest priority for care at MTFs, followed by other
beneficiaries enrolled in TRICARE Prime. 7 Beneficiaries who are eligible
for military health care, but not enrolled in

TRICARE Prime, may receive care at MTFs on a space- available basis. Active
duty members are required to use MTF care, if available. Family members and
retirees may obtain care at either military or civilian facilities,
depending on the TRICARE plan they choose.

Policy regarding health care for all DOD beneficiaries is developed by the
Office of the Assistant Secretary of Defense for Health Affairs (Health
Affairs). TMA oversees the operation of the TRICARE Program. Health

Affairs and TMA coordinate with the Air Force, Army, and Navy to implement
TRICARE, but the Surgeon General of each branch of the military has
authority over its own MTFs. TMA also oversees the TRICARE contracts with
the civilian providers.

6 Medicare is a federally financed health insurance program that covers
health care expenses of the elderly, some people with disabilities, and
people with end- stage kidney disease. Military retirees aged 65 or older
are eligible for Medicare on the same basis as civilian retirees. In 2001,
military retirees enrolled in Medicare part B (which covers physician care,
other outpatient services, and selected home health services) became
eligible for TRICARE coverage- commonly called TRICARE for Life. As a
result, TRICARE is now a secondary payer for these retirees? Medicare-
covered services- paying most of the required cost sharing. Retirees can
also obtain services at MTFs, but when they do this, DOD does not receive
payments from Medicare for those services it provides them.

7 Beneficiaries enrolled in TRICARE Plus- a new MTF primary care enrollment
program offered at selected MTFs- also receive primary care appointments
with the same access standards as TRICARE Prime enrollees.

DOD and the three branches of the military have implemented policies and
initiatives specifically aimed at improving the delivery of health services
for women. (See app. II for details.) For example, a 1998 DOD policy states
that women enrolled in TRICARE Prime shall have the option to choose a
primary care manager (PCM) 8 who has advanced training in women?s health
issues. 9 Additionally, MTFs have begun providing ?family- centered?
obstetrical care by involving the family in the continuum of care from
prenatal through postpartum. Other efforts have been aimed at educating line
commanders and beneficiaries about the importance of women?s health care
services to readiness.

DOD?s Health Care DOD offers a full range of health care services for women
beneficiaries

Benefit for Women is through the TRICARE benefit. In general, TRICARE-
covered benefits for

women reflect national clinical guidelines developed by ACOG and are
Comparable to Other

comparable to widely used FEHBP health plans. DOD- like the FEHBP Plans

plans we reviewed- requires some beneficiaries to share in the cost of their
health care. These copayments, which are the same for men and women, vary
depending on the plan option and providers selected.

DOD Health Care Services In addition to the range of health care services
offered to all DOD

for Women beneficiaries, TRICARE provides health care services targeted
specifically

to women. The benefit is uniform across all three branches of the military,
and generally for all beneficiary types, including active duty members,
family members, and retirees. These services include the following primary,
specialty, preventive, and reproductive care.

8 A PCM coordinates enrollees? care and refers them to the appropriate
specialists, if needed. 9 According to DOD officials, the availability of
PCMs with advanced training in women?s health care may be limited.

 Comprehensive obstetrical and gynecological care, including care related
to pregnancy and family planning, and screening for gynecological cancers: 
prenatal, maternity, and postpartum care, including HIV and

Hepatitis B screening for pregnant women, and genetic testing when medically
indicated to determine if an unborn child has genetic defects, 10 and

 family planning, including contraceptives, diagnosis and treatment of
infertility, and sterilization;

 pelvic exams and Pap smears;  breast examinations and mammography; 
breast reconstructive surgery for mastectomy patients and other breast

surgery; 11  hormone replacement therapy and counseling regarding the
benefits

and risks of hormone replacement therapy for menopausal women; and  bone
density studies to diagnose and monitor osteoporosis, osteopenia,

and for those at high- risk of bone disease. TRICARE Health Benefits

The TRICARE benefit is consistent with the guidelines for women?s health for
Women Are In Line With

issued by ACOG for primary, specialty, preventive, and reproductive care.
National Guidelines and

TRICARE benefits are also comparable to the range of benefits for women
Other Health Plans

offered under two FEHBP health plans- BlueCross and BlueShield Service
Benefit Plans (BlueCross BlueShield), a fee- for- service and preferred
provider plan with the largest number of participants in FEHBP; and Kaiser

10 TRICARE covers genetic testing if the mother is aged 35 or older or had
rubella during the first 3 months of pregnancy, or has a family history of
genetic defects. 11 TRICARE covers cosmetic, reconstructive, and plastic
surgery for breasts in the following cases: (1) correction of a congenital
anomaly, (2) restoration of body form (including revision of scars)
following an accidental injury, (3) revision of disfiguring and extensive

scars resulting from neoplastic surgery, and (4) reconstructive breast
surgery following a medically necessary mastectomy performed for the
treatment of carcinoma, severe fibrocystic disease, other nonmalignant
tumors, or traumatic injuries.

Foundation Health Plan of the Mid- Atlantic States, Inc. (Kaiser), one of
the FEHBP?s largest HMO plans. Specifically, BlueCross BlueShield and Kaiser
also offer the full range of women?s health care services covered by TRICARE
as listed above, including obstetrical and gynecological care,

maternity care, family planning, mammography, reconstructive breast surgery,
hormone therapy, and bone density studies. For example, TRICARE coverage for
Pap smears and mammograms is in line with the FEHBP plans that we reviewed
as well as with ACOG guidelines that call for screenings based on age and
risk. (See table 1.)

Table 1: Comparison of TRICARE Pap Smear and Mammogram Standards With ACOG
Guidelines and Other Plan Standards FEHBP HMO

FEHBP Fee- for- service ACOG TRICARE (Kaiser) (BlueCross BlueShield)

Pap smear Preventive care includes a routine

Preventive care includes a Preventive care includes a

Preventive care includes a Pap smear annually when sexually

routine Pap smear annually at routine Pap smear. Regarding

routine Pap smear active or at age 18. For patients

age 18 (or younger, if sexually test frequency, members are annually for
women of any age.

age 19 and above, physician and active) until three normal tests. advised to
consult with patient discretion is recommended

After three normal tests, then physician to determine what is after three
consecutive normal test frequency is a physician appropriate. tests, if low
risk. a and patient decision, but not

less than every three years. Mammogram Preventive care includes a routine

Preventive care includes a Preventive care includes a

Preventive care includes a mammogram for women as follows:

routine mammogram for women routine mammogram for

routine mammogram for women as follows:

women as follows: as follows:

* Age 19 to 39: periodic assessment, if high risk b

 Age 40 and below: 1 baseline  Age 35 to 39: 1 baseline test

 Age 35 to 39: 1 baseline test  Age 40 to 49: 1 test every 1 to 2 test

 Age 40 to 64: 1 test every  Age 40 to 64: 1 test annually

years  Age 41 to 50: 1 test every 2 calendar year

 Age 65 and above: 1 test  Age 50 to 64: yearly

years  Age 65 and above: 1 test every 2 consecutive calendar

 Age 65 and above: periodic  Age 50 and above: yearly.

every 2 consecutive calendar years.

assessment. years.

a ACOG recommends more frequent Pap tests when one or more high risk factors
is present, for example, women who have had multiple sexual partners and
women with a history of sexually transmitted diseases.

b For mammograms, high risk is defined as women who have had breast cancer
or have a first- degree relative (that is, mother, sister, or daughter) or
multiple other relatives who have a history of premenopausal breast, or
breast and ovarian, cancer.

Sources: ACOG guidelines effective in 2002, DOD TRICARE benefit for 2002,
Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc. for 2002,
and BlueCross BlueShield Service Benefit Plans for 2002.

Benefits not provided under TRICARE are also comparable to the benefits not
covered under the FEHBP plans we reviewed. For example, TRICARE does not
cover

 over- the- counter contraceptives or over- the- counter pregnancy tests, 
artificial insemination including in vitro fertilization,  routine genetic
testing to determine paternity or child?s gender,  surgery to reverse
sterilization, and  abortion, except when the life of the mother is
endangered. 12 BlueCross BlueShield and Kaiser generally do not cover these
services either, although there are limited exceptions. For example, Kaiser
covers artificial insemination and in vitro fertilization in certain cases.
13 While in vitro fertilization services are not covered under the TRICARE
benefit, DOD officials told us that these services are offered with a
required patient copayment at five MTFs: Keesler Air Force Base, Biloxi,
Mississippi; Naval Medical Center, San Diego, California; Walter Reed Army
Medical Center, Washington, D. C.; Wilford Hall Medical Center, San Antonio,
Texas; and Wright- Patterson Air Force Base, Dayton, Ohio. 14

12 See 10 U. S. C. sect. 1093. This statute places the following restrictions on
abortions: (a) funds available to DOD may not be used to perform abortions
except where the life of the mother would be endangered if the fetus were
carried to term and (b) no medical treatment facility or other facility of
DOD may be used to perform an abortion except where the life of the mother
would be endangered if the fetus were carried to term or in a case in which
the pregnancy is the result of an act of rape or incest. 13 Kaiser Mid-
Atlantic offers in vitro fertilization if (1) the patient and her spouse
have a

history of infertility of at least 2 years duration as a result of
endometriosis, exposure in utero to diethylstilbestrol (commonly known as
DES), blockage of, or surgical removal of, one or both fallopian tubes,
lateral or bilateral salpingectomy, or abnormal male factors, including
oligospermia, contributing to the infertility and (2) the patient has been
unable to become pregnant through a less costly infertility treatment for
which coverage is available

under this plan and (3) the patient?s oocytes are fertilized with her
spouse?s sperm. 14 According to officials at Walter Reed, beneficiaries at
their MTF are required to pay a copayment of about $3,500 to $5,000 for in
vitro fertilization services, while in the civilian sector, the cost would
be about $8,000 to $10,000. The cost of this service may vary at other MTFs.

In addition, the TRICARE benefit requires some beneficiaries to share in the
cost of their health care- a characteristic also found in the FEHBP plans we
reviewed. However, the various plan options make direct comparisons
difficult. TRICARE Prime enrollees who are active duty members or their
family members have no copayments, while Kaiser requires its beneficiaries
to pay a $10 copayment for routine screenings. TRICARE Extra and Standard
beneficiaries and BlueCross BlueShield beneficiaries share in the cost of
care, with the copayments varying depending on the plan option and the type
of provider chosen by the

beneficiary. Most Women

Overall, women beneficiaries report being satisfied with the TRICARE
Beneficiaries Are

health care benefit, but some have concerns about the type of care they
receive. Generally, these concerns stem from where beneficiaries are
Satisfied With DOD?s located and their expectations about the types of
providers, sources of

Health Care Benefit, care, and supplies that should be available. For active
duty women, the

but Some Concerns attitudes of the command personnel can also influence
women

beneficiaries? satisfaction. Exist DOD Survey Data Indicate

According to DOD survey data from 2000, women beneficiaries report Women Are
Generally being generally satisfied with the TRICARE health benefit and
their access to health care services. 15 Results of this survey indicate
that women are as Satisfied With Health Care satisfied as men with their DOD
health plan on four measures pertaining to Services

their experiences with their providers and accessing care. For example, the
average rating from women for the health care they received in the last 12
months from all providers was 7. 8 on a scale where 10 represents the best
health care possible- the same rating as given by men. In addition, 85

percent of women and 87 percent of men reported that they were usually or
always satisfied with how well providers communicated. (See table 2.)

15 The Health Care Survey of DOD Beneficiaries is a recurring survey that
asks a sample of eligible beneficiaries to comment on their health, the
availability of health services, and their level of satisfaction with health
services.

Table 2: Women Beneficiaries? Responses to Measures of Satisfaction Compared
to Men?s

Measure Women Men

Average rating of all health care in the last 12 months from all doctors 7.8
7. 8 and other health providers (on a scale where 10 represents the best
health care possible)

Average rating of all experiences with health care plan (on a scale 7.3 7. 1
where 10 represents the best health plan possible) Percent who reported that
getting needed care was not a problem 68 67

Percent who reported that they were usually or always satisfied with 85 87
how well doctors and other health care providers communicated Source: DOD?s
Health Care Survey of DOD Beneficiaries for year 2000.

Some Women Beneficiaries While most of DOD?s women beneficiaries are
satisfied with the care they

Have Concerns About the receive, some have expressed concerns about their
health care. These

Available Care concerns generally stem from the beneficiary?s location-
overseas, in

remote areas, or in deployed settings- and expectations about the type and
source of care available. For active duty women, concerns also stem from the
attitudes and the climate established by the command personnel who may not
understand women?s health care needs.

Some Concerns Are About Care Military beneficiaries- both men and women-
stationed in overseas or

in Overseas, Remote, and remote locations provide a significant challenge
for DOD's health system. 16 Deployed Settings

In locations overseas, DOD supplements its MTF care with civilian host
nation care, where medical practice, language, and culture can differ
significantly from U. S. civilian care. For example, health care in Japan
and Italy is characterized by more inpatient admissions and longer hospital
stays than in the U. S. system. In many countries, nurses and administrative
staff do not speak English, and the English fluency of doctors varies,
making it difficult for patients to discuss their medical problems with host
nation personnel. In addition, patients expressed concerns that medical
terms might not be translated accurately. Cultural differences have
similarly affected beneficiary perceptions of care. For example, in some 16
According to DOD data, over 200,000 active duty members and over 190,000
active duty

family members live overseas; and over 160,000 active duty members and over
360,000 active duty family members live in remote areas. DOD defines a
?remote? area as one in which an active duty member lives and works more
than 50 miles, or about an hour drive, from an MTF.

areas of Europe and the Pacific, doctors are unaccustomed to American
patients who may take a more active role in their health care and ask
questions about their diagnosis or treatment strategies, procedures, and

expected outcomes. As a result, these patients can become frustrated with
the more reserved attitude of host nation doctors. Other cultural
differences can create a gap in care. For example, in Japan and Korea,
patients? families, not nursing staff, typically provide sheets, towels, and
toiletries and assist patients during hospitalizations. In 2000, we reported
17 that differences such as these have caused frustrations for some

beneficiaries- both men and women- and in some cases have resulted in their
delaying care until they can travel to an MTF. Remote locations- both in the
United States and overseas- also present a

challenge to DOD in providing care to all of its beneficiaries. In 2000, we
reported 18 that, according to DOD, there are some deficiencies in provider
availability in rural areas of TRICARE regions in the United States. 19 In
remote areas, beneficiaries can have difficulty finding providers,
especially for certain types of specialty care, and often have to follow the
accepted community access standards, which may require traveling a long
distance to obtain care. For example, in some parts of South Dakota, a 2-
hour drive is considered routine, and in Alaska, all patients are
transported to the lower 48 states for certain types of care. In remote
locations overseas, many of DOD?s beneficiaries rely on the State Department
to provide or help arrange their medical care through a list of local
providers who meet

U. S. medical standards. 20 17 U. S. General Accounting Office, Defense
Health Care: Resources, Patient Access, and Challenges in Europe and the
Pacific, GAO/ HEHS- 00- 172 (Washington, D. C.: Aug. 31, 2000). 18 U. S.
General Accounting Office, Military Health Care: TRICARE?s Civilian Provider
Networks, GAO/ HEHS- 00- 64R (Washington, D. C.: Mar. 13, 2000). 19 To
address provider availability deficiencies, in October 1999 DOD implemented
TRICARE Prime Remote (TPR) for active duty members stationed in the U. S.
who live and work more than 50 miles from an MTF. Eligible active duty
members are required to enroll in TPR. TPR enrollees have access to (1) a
PCM to manage their health care, authorize specialty care referrals, and
file claims, and (2) health care finders- contract staff accessed by toll-
free

numbers- to help identify primary and specialty care providers and process
referrals. DOD plans to expand the program to include family members by
September 2002. In the meantime, copayments are waived for family members
eligible for TPR. 20 GAO/ HEHS- 00- 172.

In deployed settings, such as in the field or on a ship, active duty members
may be limited in the choice of health care services and supplies available
since DOD tailors the medical capability to the setting and the size of the
unit deployed. For women, this constraint has raised concerns about privacy.
In 1999, we reported that women deployed to Bosnia described the base camp
clinics as very small and lacking interior walls and doors to shield
individuals being examined. 21 These deployed women also had concerns that
their medical problems would not be kept confidential by

staff at the clinics and that word of their visit would be known around the
camp. Deployed women also raised concerns about the availability of
supplies, such as feminine hygiene products and birth control pills, in the

field or on ships. Due to limited storage space, women may not be able to
obtain their preferred brand, but most women were able to obtain adequate
supplies. At the end of 2001, DOD officials and representatives from
beneficiary groups told us that these concerns remain among deployed women.

Some Concerns About Care Stem According to DOD officials, some women
beneficiaries were dissatisfied

From Beneficiary Preferences with the care they received or were reluctant
to seek available care

because of certain expectations about the type of provider they should see
and the setting in which they should receive their care. Several DOD
officials told us that some women expressed dissatisfaction or reluctance

to seek care from a provider who they perceive to be inexperienced or
insensitive to women?s issues or who is male. These officials also told us
that some women prefer or expect to see a doctor who specializes in

obstetrical and gynecological care for their gynecological examinations.
This preference or expectation is generally the result of their believing
that specialists are better qualified than generalists, such as internists
or family practice doctors. According to DOD officials, while obstetrical
and gynecological specialists are needed for some procedures, generalists,
physician assistants, or nurse practitioners can provide routine care and
perform preventive tests. According to beneficiary representatives from
DACOWITS and NMFA, women also expressed dissatisfaction with the

lack of continuity of care because they did not see the same provider from
visit to visit. Finally, DOD officials also said that active duty women
noted that they were reluctant to seek care from a provider who is a peer or
junior in rank, or is someone with whom they socialize. This can be a

21 U. S. General Accounting Office, Gender Issues: Medical Support for
Female Soldiers Deployed to Bosnia, GAO/ NSIAD- 99- 58 (Washington, D. C.:
Mar. 10, 1999).

particular problem in some deployed settings where the number of medical
staff is limited.

DOD officials also reported that women have preferences for where they
receive their maternity care. According to DOD officials, some women prefer
to have their babies delivered in civilian hospitals instead of MTFs.
Additionally, results from a DOD survey on inpatient care during childbirth
at selected MTFs show that some women reported problems with obstetrical
care received at MTFs. 22 According to survey results from 2000,

26 percent of women beneficiaries reported dissatisfaction with obstetrical
care at the MTF, compared to the civilian hospital average of 22 percent.
These women reported that their dissatisfaction related to coordination of
care, physical comfort, respect for patient preferences, emotional support,
involvement of family and friends, and information and education. (See app.
II for recent legislation and initiatives by the military branches to
address these concerns.)

Commanders and Beneficiaries DOD officials told us that reports from the
field have indicated that some

May Lack Understanding About line commanders, including officers and senior
enlisted personnel, may not

Women?s Health Care Needs understand the importance of women?s health care.
These officials also said in some cases, women beneficiaries also lacked an
understanding of

their health care needs. Specifically, DOD officials said that some
commanders and beneficiaries lack knowledge about women?s health issues, the
health care services available to women through DOD, when this care should
be accessed, and the need for such care. For example, some women
beneficiaries do not understand the importance of physical exams and
preventive screenings such as Pap smears and mammograms. This can be
especially problematic for women- both active duty and family members- who
are young and away from their families or other sources of

support who might provide health care guidance and teach them the importance
of primary and preventive care. 23

In some cases, beneficiaries and commanders have not been adequately trained
about the importance of women?s basic health care and its effect on
readiness. For example, according to DOD officials, neither the Army nor

22 In 2000, DOD conducted a survey to determine beneficiary satisfaction
with inpatient care during childbirth at 20 MTFs. 23 The Air Force and the
Navy require annual physical exams for all active duty members- men and
women. The Army requires annual exams for active duty women, and periodic
exams for active duty men, as appropriate (average is every 5 years for
men).

the Air Force has a program to train line commanders about women?s health
care, although the Navy has some efforts to train its leaders about these
issues. DOD officials said that, lacking this understanding, some commanders
may be reluctant to allow active duty members- both men and women- time away
from their duty station to obtain health care services- especially if the
commander perceives that their time away will negatively affect the primary
mission. For active duty women, explaining

their specific ailment to their commanding officer (usually male) or
appearing like they need special treatment may make them reluctant to seek
the care they need.

Concluding DOD offers a full range of health care services for women
beneficiaries

Observations through the TRICARE benefit. In general, TRICARE- covered
benefits for

women reflect national clinical guidelines developed by ACOG and are
comparable to widely used FEHBP health plans. In addition, the TRICARE
benefit requires some beneficiaries to share in the cost of their health

care- a characteristic also found in the FEHBP plans we reviewed. These
copayments vary depending on the plan option and providers selected.
Overall, DOD data indicate that women beneficiaries are satisfied with the

TRICARE health care benefit, but some have concerns about the care available
to them. Generally, these concerns stem from where the beneficiary is
located- overseas, in remote areas, or in deployed settings- and
beneficiaries? expectations about the type and source of care that should be
available. Concerns can also stem from the attitudes and the climate
established by the command personnel. We did not, however, determine the
prevalence of any of these concerns. Additionally, we note that some
concerns are relevant only to women, but others pertain to men as well.

Agency Comments We provided DOD a draft of our report for its review. In its
comments, DOD agreed with our findings, noting that our portrayal of DOD?s
health care

benefit for women was accurate. DOD also provided technical comments, which
we incorporated where appropriate. (DOD?s comments appear in app. III.) We
are sending copies of this report to the Secretary of Defense, appropriate
congressional committees, and other interested parties. We

will also make copies available to others upon request. If you or your staff
have questions about this report, please contact me at (202) 512- 7101.
Other contacts and staff acknowledgments are listed in appendix IV.

Marjorie Kanof Director, Health Care- Clinical and Military Health Care
Issues

List of Committees

The Honorable Carl Levin Chairman The Honorable John Warner Ranking Minority
Member Committee on Armed Services United States Senate

The Honorable Bob Stump Chairman The Honorable Ike Skelton Ranking Minority
Member Committee on Armed Services House of Representatives

The Honorable Daniel Inouye Chairman The Honorable Ted Stevens Ranking
Minority Member Subcommittee on Defense Committee on Appropriations United
States Senate

The Honorable Jerry Lewis Chairman The Honorable John Murtha Ranking
Minority Member Subcommittee on Defense Committee on Appropriations House of
Representatives

Appendi x I

Scope and Methodology Our review focused on issues related to health care
provided by the Department of Defense (DOD) that are specific to women,
including preventive and reproductive care. To address the key questions, we
analyzed pertinent documents (including policies, procedures, and survey
results) and interviewed officials from

 DOD?s Health Affairs? Office of Clinical and Program Policy,  DOD?s
TRICARE Management Activity (TMA),  the Surgeons General Offices for the
Air Force, Army, and Navy, and  the American College of Obstetricians and
Gynecologists (ACOG). We reviewed selected health care plans under the
Federal Employees Health Benefits Program (FEHBP) to compare the covered
benefits with those provided by TRICARE. We selected BlueCross and
BlueShield Service Benefit Plans, a fee- for- service and preferred provider
plan with the largest number of participants in FEHBP, and Kaiser Foundation
Health Plan of the Mid- Atlantic States, Inc., one of the FEHBP?s largest
health maintenance organization (HMO) plans. In addition, we reviewed
completed studies addressing military health care, including those we
conducted and those conducted by DOD. We also conducted a site visit to
Walter Reed Army Medical Center to review the in vitro fertilization

services offered at this military treatment facility (MTF). To further
address these questions, we agreed with the committees of jurisdiction to
conduct a high- level review to obtain DOD beneficiaries? perceptions on
women?s health care services and identify potential concerns about women?s
health care in DOD. To do this, we interviewed DOD headquarters officials
and relied on two DOD surveys: a DOD- wide health care survey on beneficiary
satisfaction and a survey targeted at inpatient care during childbirth at
selected MTFs. Both of these surveys are from 2000- the most recent data
available. We also conducted interviews with

 the Defense Advisory Committee on Women in the Services (DACOWITS), a
group that advises the Secretary of Defense on issues concerning active duty
women, including health care, and

 the National Military Family Association (NMFA), an advocacy group that
obtains beneficiary views on issues concerning military families, including
health care.

To supplement these interviews, we relied on our past work on DOD health
care.

We did not independently validate the information we received from DOD,
DACOWITS, or NMFA, nor did we determine the prevalence of beneficiary
concerns. Additionally, while our review focused on health care for women
beneficiaries, some of our findings pertained to men as well, which we have
noted in our report where appropriate. Our work was conducted from November
2001 through April 2002 in accordance with generally accepted government
auditing standards.

DOD Policies And Initiatives To Improve

Appendi x II

Women?s Health Care Over the past decade, DOD has taken a number of steps to
improve its women?s health care services in response to several factors,
such as legislation and beneficiary concerns. Notably, in 1990, DOD added
women?s health as a responsibility of its Office of Clinical and Program
Policy to formulate DOD- wide policy related to women?s health issues and to
coordinate women?s health care activities initiated by the three branches of
the military. 24 In addition, DOD has established several DOD- wide policies
to clarify TRICARE?s benefits for women. DOD has also implemented specific
initiatives that affect health care provided to women beneficiaries,
including maternity care and breast cancer care. Similarly, the three
branches of the military have developed initiatives targeted to meet the
specific needs of women patients. Many of these efforts aim to better
educate leaders and beneficiaries about the importance of women?s health
care services to readiness.

DOD- wide Policies and Since 1992, DOD has refined and enhanced some of its
policies and

Initiatives implemented several initiatives related to women?s health care.
Many of

these efforts were undertaken to respond to findings in the medical
community and concerns by the Congress, DACOWITS, and beneficiaries. Key
efforts are listed below.  In 1992, in response to DACOWITS concerns, DOD
issued a policy

regarding obstetrical care, stating that epidural analgesia would be an
option to women for normal vaginal deliveries. According to DOD officials,
this policy was based on the medical community?s findings that epidural
analgesia was the most effective method to control pain during labor and
delivery, and allowed for an alert, participating mother.

 In the early 1990s, DOD began to develop and implement the Breast Cancer
Initiative to improve early diagnosis, education, and prevention of breast
cancer for women beneficiaries. Funds were allocated through the surgeons
general of each branch of the military to the local level for beneficiary
access to breast cancer screening, diagnosis, and treatment; training of
primary care managers; and education programs. 24 The Office of Clinical and
Program Policy has several program directors assigned to

handle different issues. Currently, women?s issues are assigned to one
program director who is also responsible for mental health issues.

 In 1993, also in response to DACOWITS concerns, DOD established a policy
to clarify its standards for (1) access to and timely notification of the
results of Pap smears and mammograms and (2) the availability of obstetrical
and gynecological appointments for active duty women.

 In 1994, the National Defense Authorization Act (NDAA) authorized DOD to
establish a Defense Women?s Health Research Center at a selected medical
treatment center to coordinate research conducted

under DOD, the Department of Health and Human Services, and other federal
agencies on women?s health issues that are related to military service. The
center researches women?s health care issues such as the effect on women of
exposure to toxins and other environmental

hazards; combat stress and trauma; and mental health, including
posttraumatic stress disorder and depression.

 In 1995, DOD issued a policy refining the clinical preventive services
benefit for all TRICARE Prime enrollees based on the collective expertise of
military preventive medicine and to be more consistent with nationally
recognized standards for preventive services. These preventive services
include the following screenings specific to women: breast cancer (physical
exam and mammography); cancer of female

reproductive organs (physical exam and Pap smear); Hepatitis B for pregnant
women; and counseling about breast self- examination for cancer
surveillance.

 In 1998, DOD refined its policy on assigning primary care managers (PCM)
to beneficiaries enrolled in TRICARE Prime. PCMs coordinate enrollees? care
and refer them to the appropriate specialists, if needed. This policy states
that women enrolled in TRICARE Prime shall have the

option to choose a PCM who has advanced training in women?s health issues.
25  In 2002, NDAA included a provision that will make it easier for

TRICARE Standard beneficiaries to obtain civilian maternity care without
prior approval from the MTF. DOD is required to implement this provision on
the earlier date of either of the following: the date that a

new TRICARE Standard contract takes effect or December 28, 2003. 25
According to DOD officials, the availability of PCMs with advanced training
in women?s health care may be limited.

Specific Initiatives by In addition to these DOD- wide efforts, the branches
of the military have Each Branch of Service

implemented a number of women?s health care initiatives- some of which have
been developed by one branch of the service and then adopted by the others.
Some of these initiatives aim to improve health care for women, while others
focus on providing education to leaders and women beneficiaries to emphasize
the importance of women?s health to DOD?s readiness mission. Other education
initiatives focus on the importance of

family planning and maternity wellness. Over the past several years, the
Army, Navy, and Air Force have each implemented initiatives aimed at
improving health care for their women beneficiaries. For example, in
November 2001, all Army MTFs began using

liquid- based cytology to read Papanicolaou (Pap) smears which is a faster
test than the standard Pap test. According to Army officials, the use of
liquid- based cytology will address the readiness concerns identified during
the Gulf War. Specifically, women who had received Pap smears in their
predeployment screening and were found to have abnormal test results after
being deployed were usually returned to Europe or the United States for
additional testing or treatment. With the faster test, the Army expects to
avoid the cost of returning soldiers from a deployment and the need to back
fill these deployments. Both the Navy and the Air Force are also using the
liquid- based cytology Pap test in some locations.

The Navy?s Perinatal Advisory Board (formerly, the Birth Product Line) has
been working to keep deliveries ?in house? by improving the birth experience
at MTFs. Since its inception in 1997, the board has been assessing patient
satisfaction and health care concerns at MTFs worldwide,

including why some women choose MTFs and why others choose civilian
facilities to deliver their babies. Every Navy MTF worldwide is in the
process of implementing ?family- centered care? to better coordinate care
within the facility and to involve the family in the continuum of care from
prenatal through postpartum. The Army and the Air Force have also begun to
focus on obstetrical care at their MTFs.

The Air Force also has several other initiatives related to improving
women?s health care. For example, in 2000, the Air Force began pilot testing
?Project Athena? at Aviano Air Force Base in Italy, to provide specialty
care in areas- such as obstetrics and gynecology- where it does not have
sufficient patient populations to permanently assign several specialists.
While Aviano?s workload was sufficient to support one obstetrical and
gynecological doctor, it was not enough to support two,

although more than one was needed at times. To meet these needs, the Air
Force assigned one obstetrical and gynecological specialist full- time, and
rotates other specialists to the MTF on temporary assignments- usually 90
days. In addition to providing patients access to specialized care, these
rotations have given specialists enough work to keep their skills current.
The Air Force has expanded this initiative of rotating obstetrical and
gynecological doctors to another location- Misawa Air Force Base in Japan.

Some of the military branches? health care initiatives for women were
developed by one branch and then adopted by the others. For example, the
Army and the Air Force have developed deployment readiness guides for active
duty women and their leaders. The need for such guides was demonstrated in
1999, when we reported 26 that 51 percent of women deployed to Bosnia stated
that they had not received any information on women- specific health care
and hygiene practices in the field prior to

deployment. The Army?s Female Soldier Readiness Guide- which covers areas
such as field needs, health care preventive measures in the barracks, and
pregnancy- suggests strategies for leaders and soldiers to ensure female
readiness. The Air Force?s Female Airman Readiness Guide is based on the
Army?s readiness guide and, like the Army guide, aims to enable military
leaders to effectively manage women in the Air Force by addressing topics
such as hygiene in the field and pregnancy counseling.

Each military branch is also developing systems for tracking women?s routine
gynecological exams, including Pap smears. Currently, the Air Force reviews
the health needs of active duty women and men annually during a preventive
health appointment and makes recommendations for further care based on their
medical history. For example, during this annual visit, active duty women
are told when they are due for their next gynecological exam. In addition,
the Army is working on an Army- wide initiative to track active duty women?s
Pap smears so they can notify them of their annual exams, thereby helping to
ensure they receive needed care. This initiative is in the planning stages
and has not been implemented, although in the meantime some individual
installations have tracking processes in place. Similarly, the Navy has no
Navy- wide mechanism for tracking annual exams for women, although there is
some tracking of Pap smears at the MTF level. 26 GAO/ NSIAD- 99- 58.

Many of the Army?s, Navy?s, and Air Force?s education initiatives aim to
educate leaders and beneficiaries about health care services for women,
including family planning and pregnancy wellness. According to Army
officials, unplanned pregnancies can disrupt work and training situations.
Army officials told us various studies show that more than half of births to

active duty women in the Army are from unplanned pregnancies. In response,
the Army has developed several initiatives to provide beneficiaries with the
knowledge to make informed decisions about having children and taking
appropriate care measures while pregnant.  The Center for Health Promotion
and Preventive Medicine (CHPPM) is

developing a Personal Responsibility Program, including an Armyspecific
curriculum for soldiers. Its purpose is to provide soldiers with better
skills for reducing unplanned pregnancies, including education on
reproduction and contraception as well as meshing family planning with
career and financial planning. Following pilot testing, this program may

be implemented Army- wide.  The Army?s Office of the Deputy Chief of Staff
for Personnel convened a

multidisciplinary work group that is looking at many aspects of parenthood
and its effects on readiness, including unplanned pregnancy and physical
training for women after birth. Its intent is to develop a comprehensive
reference manual for military leaders to use in managing the myriad issues
connected to parenthood.

 CHPPM, with the assistance of a contractor, is developing a certification
program for physical training during pregnancy and postpartum. The intent of
this program is twofold: to provide Army certification in pregnancy fitness
and to provide a safe, standardized program for pregnant and postpartum
soldiers. Most women may exercise safely throughout pregnancy within ACOG
guidelines and under the advice of

their health care provider. Exercise during pregnancy helps prevent unwanted
body fat gain and promotes a faster return to physical readiness levels.
According to Army officials, one Army study suggested that active duty women
who participated in a pregnancy wellness program were more likely to pass
the postpartum height/ weight requirements than those who did not
participate in a structured physical fitness program. In addition, they told
us that other studies showed that

the caesarian section rate was lower among fitness program participants than
the national average, and there were no increases in adverse outcomes to
either the pregnant soldiers or their fetuses or infants. They also said
that preliminary Army data from the initial pilot

program indicate that there is a beneficial effect on labor and that
military readiness is promoted following a regular special exercise program.
The Navy and Air Force have also developed initiatives on family planning

and pregnancy wellness. For example, the Navy?s Environmental Health Center
developed a program called the Sexual Health and Responsibility Program
(SHARP) to provide sexual health and responsibility training Navy- wide to
both leaders and active duty members through the Internet and CD- ROMs. In
addition, the Navy?s CHOICES program provides sailors with education on
sexually transmitted diseases, pregnancy, relationship building, and sexual
responsibility. The goal of the program is to assist

sailors in making better choices, which will reduce the number of unplanned
pregnancies. CHOICES is available at selected commands, including in San
Diego where the Deployment Program Manager of the Fleet Family Services
Center has indicated that male and female sailors at Naval Station San
Diego, including all shipboard personnel, are required to attend this
program. The Navy?s recruit training also includes a component on conception
and contraception. Specifically, in the seventh week of basic training both
females and males attend a program called Recruit Education to Achieve
Health (REACH) that includes training on sexual responsibility, family
planning, and emergency contraception. The Air Force supports the

use of doulas- specially trained women to help other women, particularly
first- time mothers, during pregnancy and childbirth- as long as this does
not interfere with providing care. A national society of doulas has offered
their services free of charge to women beneficiaries. According to Air Force
officials, this service could be particularly beneficial to women whose
husbands have been deployed.

The branches of the military have provided education on women?s health
through targeted web sites or a CD- ROM. For example, a Navy website
provides information about dysuria, family planning, and emergency
contraception. It also provides information on the breast care centers at
the National Naval Medical Center in Bethesda and the Naval Medical

Centers at San Diego and Portsmouth. The Navy also developed the Operational
Obstetrics and Gynecology CD- ROM to serve as a selfcontained resource on
obstetrical and gynecological care for health care providers of all levels
from corpsman through physician providers who are

deployed and ashore, stationed away from an MTF or other hospital. According
to Navy officials, the fact that it does not require Internet access is
crucial during deployment. The CD- ROM is a refresher on the full range

of women?s health care from Pap smears, family planning, gynecological

emergencies, and obstetrical care through menopause. It also includes DOD-
wide medical instructions pertinent to all three military branches and
copies of the female readiness guides for the Army and Air Force. The CDROM
has been distributed to the Air Force, Army, Coast Guard, and various
international military medical forces.

Appendi x III Comments from the Department of Defense

Appendi x IV

GAO Contacts and Staff Acknowledgments GAO Contacts Kristi A. Peterson (202)
512- 7951 Linda L. Siegel (202) 512- 7150 Staff

Contributors to this report were Ann Calvaresi- Barr, Cynthia D. Forbes,
Acknowledgments

Janice S. Raynor, Mary W. Reich, and Karen Sloan.

(290137)

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Appendix I Scope and Methodology

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Appendix II

Appendix II DOD Policies And Initiatives To Improve Women?s Health Care

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Appendix II DOD Policies And Initiatives To Improve Women?s Health Care

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Appendix II DOD Policies And Initiatives To Improve Women?s Health Care

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Appendix III

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Appendix IV

United States General Accounting Office Washington, D. C. 20548- 0001

Official Business Penalty for Private Use $300

Address Correction Requested Presorted Standard

Postage & Fees Paid GAO Permit No. GI00
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