United States General Accounting Office

GAO Report to the Honorable Ike Skelton

House of Representatives

July 1995 DEFENSE HEALTH

CARE

Problems With Medical

Care Overseas Are

Being Addressed

GAO/HEHS-95-156

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-259399 

July 12, 1995

The Honorable Ike Skelton

House of Representatives

Dear Mr. Skelton:

The American military presence in Europe has declined dramatically since

1989. The active duty population has been reduced by 57 percent—from

about 322,000 to 138,000. At the same time, the military health services

system (MHSS) has also been substantially cut back. During this period of

downsizing, many beneficiaries have expressed concern about their

reduced access to health care from military medical facilities overseas and

dissatisfaction with care they received from host nation providers. They

have charged that the Department of Defense (DOD) is not doing enough to

ensure access to appropriate health care during the drawdown.

Citing these concerns, you asked that we review beneficiary access to

military health care in Europe. Specifically, you asked that we provide

information on (1) the availability of health care in military facilities,

(2) any obstacles to providing that care, (3) the experiences of

beneficiaries that have used host nation providers as an alternative to

military health care, and (4) whether DOD is addressing service delivery

problems and beneficiary concerns.

To develop this information, we visited 15 military communities in

Germany and northern Italy. Many of the beneficiary complaints about

medical and dental care that were made to DOD and Members of Congress

originated in these communities. While there, we conducted numerous

interviews with military health care providers, officials in host nation

facilities, and beneficiaries.

We also held discussions with and reviewed available documents provided

by the military medical leadership in Europe, officials in the Offices of the

Surgeons General, and top officials in the Office of the Assistant Secretary

of Defense (Health Affairs). Appendix I contains a more detailed

discussion of our scope and methodology.

Results in Brief Since the downsizing began in 1989, beneficiaries have generally found it

more difficult to obtain health services at military facilities. Beneficiaries

have access to primary care, but for some, particularly non-active duty

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beneficiaries, access to specialty care varies and is often inconvenient.

Military medical personnel must overcome many obstacles to provide the

care that is offered. These personnel are hampered by staff shortages, long

waits for laboratory test results, and equipment failures.

The reduced military health care system has resulted in DOD’s placing a

greater reliance on the German and Italian medical systems for providing

treatment to beneficiaries. Beneficiaries, however, must contend with

language barriers, cultural differences, unfamiliar doctors, quality of care

concerns including differences in treatment, and a general lack of

information about how to obtain host nation care. Additionally, active duty

family members using host nation providers were, until October 1, 1994,

required to pay deductibles and copayments for their care.

To address these problems and concerns, DOD has taken or is planning to

take a number of actions. For example, DOD is developing an interservice

health care plan for all beneficiaries in Europe that seeks to maximize the

use of military medical facilities supplemented by a network of German

and Italian health care providers. DOD has also hired liaison personnel to

help beneficiaries obtain health care from German and Italian providers.

DOD now pays the deductibles and copayments of families of active duty

members who obtain after-hours emergency services or routine care at

host nation facilities. DOD also plans to contract for (1) services to monitor

the care that beneficiaries receive from host nation providers, (2) an

education program that explains beneficiary health care options in

Europe, and (3) the translation of host nation medical records. Although

each of these actions is positive, some have been slow to materialize. DOD’s

goal is to have all of these measures in place by October 1995.

Background The MHSS consists of military medical facilities and private sector health

care providers. The primary mission of the MHSS is to maintain the health

of military personnel and to support the services during time of war. In

addition, the MHSS provides health care to dependents of active duty

members, retirees and their dependents, and survivors of service

members. Active duty members receive their care almost entirely from

military medical facilities. When space and resources are available, other

beneficiaries may obtain their care from military medical facilities as well.

Overseas, U.S. civilian government employees are also eligible to receive

care in military medical facilities on a space-available basis.

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The collapse of the Warsaw Pact and the end of the Cold War have

significantly changed the American military landscape in Europe. Because

of the easing of East-West tensions, the United States has chosen to

substantially reduce its military forces in Europe. Between July 1990 and

April 1993, DOD initiated three major plans to reduce its military forces in

Europe, each with successively lower personnel levels. The first plan,

developed in July 1990, would have reduced military positions in Europe

to 225,000; the second to 150,000; and the latest plan calls for about

100,000 Army, Air Force, and Navy personnel in Europe by the end of

fiscal year 1996.

The U.S. military medical system in Europe has also been reduced and

reorganized. The number of military hospitals and clinics in Europe is

being cut from 23 hospitals and 89 clinics in 1989 to 9 hospitals and 48

clinics in 1995. In Germany, for example, the Air Force is reducing its

hospitals from three to one and its clinics from six to five. Army hospitals

and clinics in Germany are being reduced from 9 to 3 and 55 to 25,

respectively. In northern Italy, the Air Force has one clinic and the Army

has one hospital and one clinic, the same as in 1989. The Army, however,

plans to convert the hospital to a clinic in October 1995 because (1) very

low utilization makes it difficult to maintain a high-quality hospital and

(2) quality medical care is available from host nation providers. Appendix

II lists those Air Force and Army medical facilities operating as of April 21,

1995.

The number of dental clinics is also being significantly cut back. Prior to

the downsizing, the Army had 94 dental clinics in Europe. The Army has

completed its reduction and now has 35 dental clinics. The Air Force is

reducing its dental clinics from 31 to 11.

Beneficiaries Have

Access to Primary

Care but Specialty and

Dental Care Are

Limited

Beneficiaries have access to primary care at military facilities, including

outlying clinics. Most of the outlying clinics are closed in the evenings and

on weekends, however, necessitating that after-hours primary care and

emergency services be obtained from German and Italian providers. In

general, U.S. military specialty care is available to active duty personnel

and is most accessible to beneficiaries living near U.S. military hospitals.

Dental care is more readily available to active duty personnel than other

beneficiaries.

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B-259399 

Most Beneficiaries Can

Obtain Primary Care at

Military Facilities

Military providers told us that primary care clinics are able to serve most

beneficiaries. Since 1989, the ratio of primary care providers (general

medical officers, family practice physicians, physician’s assistants, and

nurse clinicians) to beneficiaries has improved—from 1:1,222 to

1:868—and plans call for further improvement to 1:661 by November 1995.

Generally, clinics are open Monday through Friday, and some have

extended hours—one evening during the week or morning hours on the

weekend. Two Army clinics in Germany are open 24 hours, 7 days a week.

Beneficiaries in all categories expressed general satisfaction with their

access to primary care in military facilities. They did, however, express

frustration over difficulties in making appointments by telephone and

delays in obtaining routine physical exams and well-woman exams. They

also stated concerns about delays in obtaining test results.

Although the overall ratio of primary care providers is improving, staff at

many of the outlying clinics we visited mentioned that they need more

physicians trained in family practice and pediatrics. Some of the clinics

had no family practice, pediatric, or other primary care specialty physician

except the clinic commander who also had administrative and supervisory

responsibilities. Army clinics rely heavily on general medical officers to

provide primary care. Army officials stated that they do not have enough

family practice or other specialty-trained primary care physicians to assign

to clinics.

Access to Specialty Care in

Military Facilities Varies

and Can Be Inconvenient

DOD was unable to provide us with data to compute how the ratios of

specialists to beneficiaries have changed since 1989 or to measure how

long it takes to get an appointment with a specialist. However, the military

medical leadership, military physicians, and beneficiaries all commented

that there has been a significant reduction in the amount and location of

U.S. military specialty care available in Europe since the downsizing

began. As a result, access to specialty care varies by specialty and among

categories of beneficiaries.

Some specialty areas have substantially fewer physicians than before the

downsizing began. For example, the number of Army

obstetricians/gynecologists has been reduced from 42 to 17; urologists

from 6 to 2; otolaryngologists (ear, nose, and throat) from 8 to 4; general

surgeons from 32 to 11; and orthopedic surgeons from 26 to 11. Only one

specialty (nephrology), however, is no longer available in Europe.

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B-259399 

Active duty members are generally able to obtain the specialty care they

need, although in some instances they must wait a month or longer.

Service members needing inpatient psychiatric services are sometimes

sent back to the United States for such care because of limited inpatient

mental health resources in Europe. Non-active duty beneficiaries have

less, and in some cases no, access to specialty care, particularly

otolaryngology, orthopedics, and mental health—also because of limited

resources. Beneficiaries and military medical officials commented that

many people who need these services must either wait a substantial period

of time to get the care from military facilities in Europe or return to the

United States for it.

Access to specialty care is also less convenient because of the reduction in

U.S. military hospitals. In 1989 the Army had nine hospitals in Germany.

Now U.S. military specialty care is provided almost entirely in the three

remaining Army hospitals in Germany: Landstuhl, Wuerzburg, and

Heidelberg. Beneficiaries in Augsburg, for example, must travel about 130

miles one way to obtain the specialty care that is available at the U.S.

Army hospital in Wuerzburg or about 170 miles one way to Landstuhl to

obtain specialty care that is not available in Wuerzburg. Beneficiaries in

many communities throughout Germany find themselves in similar

circumstances.

Obtaining specialty care is also inconvenient for beneficiaries when repeat

hospital visits are required. For example, most outlying clinics do not have

physical therapists or mental health professionals on staff. Consequently,

patients must travel to one of the military hospitals to obtain these

recurring services. Each visit frequently requires patients to spend a full

day traveling and receiving services.

To help beneficiaries living in remote areas, specialists assigned to the

three Army hospitals periodically visit clinics to provide care, but these

visits are infrequent. Also, military communities provide shuttle bus

service to the nearest U.S. military hospital. In most communities, the

shuttle bus makes one trip daily between the military community and the

hospital, leaving early in the morning and returning in the late afternoon of

the same day. In some communities, however, the service is limited to only

a few days each week. Regardless, making long trips for follow-up

appointments created hardships on family members and active duty

service members with family and work responsibilities. Also, we were told

that soldiers’ full-day absences from their assigned duties can adversely

affect their units’ wartime readiness.

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In northern Italy, the Army plans to convert its hospital in Vicenza to an

outpatient clinic in October 1995. The clinic will maintain an after-hours

acute care capacity to treat minor injuries and illnesses. Emergency and

specialty care, now available at the Vicenza Army hospital, will be

provided by the city hospital in Vicenza, by other Italian facilities, or by

military facilities in Germany or the United States. (For some time now,

life-threatening emergencies have been sent to Vicenza’s city hospital.) For

other military communities in northern Italy, such as Aviano and Livorno,

specialty care will continue to be provided by host nation facilities, as it

has since 1989.

Relatively few military retirees and their dependents age 65 and older live

overseas. Those that do are especially concerned about their access to

specialty health care because Medicare coverage does not extend to

beneficiaries living overseas. DOD estimates that fewer than 1,400 such

beneficiaries reside in Europe. These beneficiaries, who have chosen to

reside overseas, have been largely dependent on the military health care

system to provide their medical care and, as a result, many have never

purchased supplemental health insurance through U.S. or host nation

health companies. Obtaining private insurance may not be an option for

some elderly retirees and family members because it is costly.

Dental Care Is Limited Access to dental care is limited for many beneficiaries living in Europe.

Active duty personnel have better access to dental care than do their

family members, who are generally able to obtain only emergency dental

care, annual examinations, and cleanings. Many beneficiaries, except for

active duty, have limited or no access to specialty dental care. The dental

staff in some clinics dedicate most of their orthodontic care to patients

whose treatment programs were initiated in the United States. New cases

are seldom started. In Vicenza and Livorno, all beneficiaries have access to

dental services.

Many beneficiaries and U.S. military dentists do not consider host nation

dental care a viable option. It is expensive, and beneficiaries do not like

the differences in the practice patterns of host nation dentists.

The MHSS in Europe

Faces Numerous

Obstacles

Numerous obstacles confront the MHSS in Europe. Some existed prior to

the downsizing, including medical staffing shortages, long waits for

laboratory results, and equipment problems. Many U.S. military physicians

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B-259399 

stated that these obstacles hinder their ability to provide quality medical

care.

MHSS Faces Personnel

Shortages and Other

Staffing Problems

Many clinic and hospital officials we met with stated that they have too

few military and civilian personnel. Their facilities are staffed at less than

100 percent of authorized military levels in such positions as nurses,

medics, X-ray technicians, and pharmacy technicians. In addition, medical

staff frequently complained about shortages in civilian personnel,

including receptionists, custodians, and patient liaisons. Medical staff are

working long hours attempting to meet the demand for care.

Two other factors have had a serious impact on the military’s ability to

meet the health care needs of all beneficiaries in Europe. First, medical

and dental units have been under additional strain to meet the demand for

care during the downsizing. The military had intended to keep medical

resources in Europe at levels proportionally higher than nonmedical units

so that access to health care would be improved during the downsizing. To

the contrary, many of the health and dental clinics we visited were staffed

at their so called “endstate” levels, while nonmedical units had not yet

reached their final levels. Army officials were unable to provide

documents showing how a coordinated withdrawal of medical and

nonmedical personnel was planned to ensure improved access to health

care. However, they did provide data indicating that the ratios of total

medical personnel to beneficiaries have changed little since 1989—from

1:31 to 1:38. Over time, as more units withdraw from Europe, this tension

should ease somewhat.

Second, until recently, Army medical units have not received replacements

when their medical personnel are temporarily reassigned to other units.

Between October 1993 and December 1994 the Army in Europe sent 715

men and women from medical units to other areas of the world without

providing replacement personnel for the affected medical units. These

actions often resulted in immediate personnel shortages for the medical

units in Europe and further hindered the delivery of health care to

beneficiaries there. The Army has implemented a policy which calls for

replacing medical personnel (not necessarily on a one-for-one basis) who

are temporarily assigned to other units for more than 14 days. Since

March 1995, the Army has provided temporary replacements to medical

units in Europe.

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Equipment Problems and

Untimely Laboratory Test

Results

Medical staff experience daily problems with equipment failures and

delays in obtaining laboratory test results. Generally, these problems are

attributed to old and unreliable equipment. Staff repeatedly told us that

X-ray, X-ray processor, and culture machines are frequently broken. They

also mentioned that problems exist with the ambulance fleet,

defibrillators, CT scanners, and pulse oximeters because they are old,

outdated, or in short supply.

Medical staff also experience problems in obtaining laboratory test results.

Although data were unavailable on the specific or average times needed to

get laboratory results, staff said that all test results require more time than

they should to get back. Results of glucose, potassium, cholesterol, liver

and thyroid function, and tissue exams are typically delayed, as are X rays.

Health care providers at one clinic estimated that it took between 2 and 4

weeks to obtain the results for such tests. They cited delays as long as 2

months for Pap test results. DOD is currently implementing a medical

information system that will allow providers to obtain test results via

computer rather than mail. The new computer system, officials believe,

should enable military providers to get laboratory results in a more timely

manner.

Beneficiaries Are

Frustrated When

Obtaining Host Nation

Care

Beneficiaries under age 65 who either are unable or do not want to receive

care from military medical facilities have the option of obtaining care from

host nation providers.1

 Although the beneficiaries we spoke with were

generally satisfied with the outcome of the host nation health care they

received, they expressed a great deal of frustration over their specific

experiences in obtaining that care. They also expressed a strong

preference to receive their health care from military facilities.

Beneficiaries and military medical officials agree, however, that as less

and less care is available from military medical facilities in Europe,

beneficiaries will have to rely more on host nation providers.

Beneficiaries are frustrated with host nation medical care for a variety of

reasons. Some host nation providers, for example, require payment or a

large deposit in advance of treating U.S. military beneficiaries. These

upfront payments, we were told, amount to as much as the equivalent of

about $6,000. Also, U.S. military officials provide beneficiaries little

information or help in choosing German or Italian providers. Essentially,

1

The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), allows non-active

duty beneficiaries to obtain health care from private sector medical care providers. The most current

data available indicate that, in fiscal year 1993, CHAMPUS costs in Germany and Italy were about

$30 million.

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B-259399 

beneficiaries are given a list of English-speaking doctors and encouraged

to ask other beneficiaries about their experiences with these doctors

before selecting one. In addition, beneficiaries feel abandoned by military

medical physicians when they use host nation providers. In general,

military physicians are not required to actively monitor U.S. patients’ care

in host nation facilities. Although they may be aware of their patients’

progress, the lack of direct contact gives beneficiaries the impression that

they have been “dumped” on host nation providers and that the military is

not concerned about their care. The Aviano community is an exception.

Several patient assistance services have been in place for some time there.

For example, the Air Force contracts with bilingual Italian physicians to

help beneficiaries understand their diagnosis and treatment.

Beneficiaries also mentioned that they need help obtaining services from

host nation facilities, especially during evenings and weekends. They are

concerned about such matters as knowing where to go, having someone

available to translate their medical emergency, and getting assistance with

paperwork. In addition, beneficiaries using host nation providers were

required to pay deductibles and copayments for their care. When admitted,

beneficiaries explained that they must contend with language barriers,

cultural differences, and quality of care concerns such as differences in

treatment. Military physicians told us that some differences in treatment

do exist among the U.S., German, and Italian systems. Although the

cultural and treatment differences are unsettling to U.S. patients, the

military medical staff, for the most part, are confident about the quality of

health care delivered in Germany and northern Italy.

Once care is completed and patients are released from host nation

providers, many patients are left with their medical information in a

foreign language. This problem is most prevalent in Germany where,

currently, treatment records are written in German, and often the only

information translated is that done by bilingual physicians working for the

U.S. military. In several communities, military physicians estimated that

less than 10 percent of medical records are ever translated. Consequently,

patients may not have an adequate record of their medical conditions and

treatments.

DOD Actions to

Address Beneficiaries’

Concerns

DOD and beneficiaries recognize that there must be a greater reliance on

host nation care: Rebuilding U.S. military medical facilities overseas is not

an option. Therefore, DOD has taken and is planning a number of steps to

alleviate beneficiary concerns and improve access to host nation care.

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Although some of DOD’s actions have been slow in coming, most are

expected to be in place by October 1995. In our view, these actions are

positive steps toward alleviating the concerns voiced by beneficiaries.

However, the extent to which beneficiaries will be satisfied remains to be

seen.

To address beneficiaries’ overall concern, DOD is developing an

interservice health care plan for all beneficiaries in Europe that seeks to

maximize the use of military medical facilities. This effort is being headed

by a tri-service executive steering committee made up of senior medical

officials in Europe and assisted by a military treatment facility

commander’s council—a group representing military hospital and clinic

commanders in Europe. Instead of focusing on tangible outcomes, most

efforts to date have focused on planning, coordinating, and determining

how the military services can effectively work together to better serve

their beneficiaries. These formative sessions represent a significant step

because, in the past, the services have essentially operated independently

rather than working in a collaborative way.

Beginning in the summer of 1994, DOD also initiated efforts to establish a

preferred provider network in Europe, Africa, and the Middle East. Once

completed, this network will enable beneficiaries to choose among various

host nation providers who (1) are interested in serving them, (2) are

willing to accept payment under CHAMPUS, and (3) will not require advance

payments from beneficiaries. At the outset approximately 20,000 host

nation providers were identified as having billed CHAMPUS for services. DOD

contacted these providers and asked if they were willing to treat U.S.

beneficiaries, outlining the conditions. DOD is also working to ensure the

quality of network participants by verifying their qualifications. As of

February 1995, over 4,000 of these providers had indicated an interest in

joining a CHAMPUS-preferred provider network. In April 1995, the Army

established a toll-free telephone number for beneficiaries to obtain

after-hours referrals to host nation facilities. The service is currently

available at Army hospitals in Heidelberg and Wuerzburg and is planned

for Landstuhl as well.

To assist beneficiaries who are using host nation providers, DOD

established a patient liaison coordinator program. As of June 5, 1995, 59

patient liaisons were assigned to Europe. These liaisons (1) coordinate

consultations with host nation facilities and follow-up care, (2) help make

appointments at host nation facilities, (3) educate beneficiaries on host

nation medical services, (4) interpret information between host nation

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providers and beneficiaries, (5) assist with paperwork associated with

hospitalization at host nation facilities, and (6) visit patients in hospitals.

Beneficiaries generally agree that the patient liaisons reduce the anxiety

involved in using host nation facilities. However, most communities have

only one or two patient liaisons and whose services are generally available

only on weekdays until 4 p.m. The patient liaison program is intended to

be supplemented with a volunteer system to provide coverage after

business hours. However, none of the communities we visited had yet

established a volunteer system that provided evening and weekend

coverage. Consequently, beneficiaries using host nation facilities after

normal business hours often obtained that care without assistance. In

response, DOD has agreed to increase the availability of liaisons to provide

24-hour coverage.

Effective October 1, 1994, DOD expanded an existing CHAMPUS initiative to

improve access to host nation facilities for active duty family members.

DOD estimates this initiative will cost approximately $2.8 million annually.

The expanded CHAMPUS initiative waives cost sharing for active duty family

members who obtain outpatient and inpatient care at host nation facilities.

Beneficiaries are pleased and indicated that the elimination of copayments

and deductibles has enhanced their willingness to seek care at host nation

facilities.

DOD is also planning to use host nation physicians to act as liaisons and

assist military doctors in monitoring beneficiaries admitted to host nation

facilities for care. The direct involvement of a physician representing the

military may ease beneficiaries’ feelings of being “dumped” when they are

referred to host nation facilities.

To better inform beneficiaries and thereby reduce their anxieties about

health care—military and host nation—available in their communities in

Europe, DOD is creating an education program. DOD is also planning to have

host nation medical records translated into English. This should help

ensure that in the future patients will have an adequate record of previous

medical conditions and treatments.

To improve beneficiaries’ access to dental care, DOD is taking a number of

steps. First, DOD is striving to efficiently use its existing dental capabilities,

including sharing resources among the three services. Second, DOD is

increasing the number of dentists, orthodontists, pedodontists, and other

dental support personnel assigned in Europe. The Air Force plans to

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assign an additional 23 general dentists, 2 orthodontists, 2 pedodontists,

and 54 dental assistants to Europe during fiscal year 1995. As of May 26,

1995, all but four dentists had arrived overseas. The Army has contracted

with civilians to fill 22 general dentist, 5 orthodontist, and 10 dental

hygienist positions. Third, at remote locations or areas with small

populations where military dental services may not be available, DOD plans

to arrange for dental care through host nation providers. Fourth, family

members will be allowed to remain enrolled in the Dependents Dental

Plan while the service member is assigned overseas.2

 This will permit

family members to obtain dental care in the United States, for example,

during stateside visits.

Finally, over the past year, DOD has made an effort to educate beneficiaries

on the forthcoming changes in Vicenza and to develop a plan to ensure the

availability of quality medical care. For example, it has (1) prepared a new

detailed handbook to inform patients about host nation obstetrical

services; (2) developed a questionnaire to obtain beneficiary feedback

about host nation medical care; (3) held meetings with beneficiaries to

educate them on the changes; (4) hired a host nation physician to perform

oversight and liaison services among the host nation facility, the patient,

and the military medical providers; and (5) made arrangements for

translators to assist when Italian ambulance service is needed. Several

other significant steps are described in detail in a plan DOD prepared and

sent to the Congress in March 1995.3

In February 1995, an Italian newspaper reported that the hospital in

Vicenza—the primary host nation referral facility—was alleged to have

engaged in poor health care practices. These practices included improper

disposal of contaminated waste in the emergency room, operating rooms,

and the pathologic anatomy and metabolic disease sections. Expired or

spoiled medicines were also reportedly discovered throughout the

hospital. Army medical officials in Vicenza followed up with hospital

administrators and were assured that U.S. beneficiaries did not receive

expired medicines or have resultant bad medical outcomes. Army officials

believe the situation is resolved and that beneficiaries are not at any risk.

They believe the hospital provides superb care overall. This incident does,

however, provide sufficient reason for military medical providers to

2

The Dependents Dental Plan covers spouses and children of active-duty members of the uniformed

services. It is not for active duty members or retired members. To be eligible for the Dependents

Dental Plan, dependents must reside in the United States, Guam, the U.S. Virgin Islands, or Puerto

Rico.

3

Report to Congress in Response to Section 733, Defense Authorization Act for FY95, Delay in Closure

of Army Hospital, Vicenza, Department of Defense (Washington, D.C.: 1995).

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B-259399 

remain actively involved in their patients’ care when they are referred to

host nation facilities. Army officials recognize this need and have pledged

to actively monitor all patient care in host nation facilities.

Conclusions Military health and dental care professionals are working long hours

attempting to meet beneficiary demands that are greater than military

facilities are staffed to provide. Even though some of the strain placed on

medical and dental resources may decrease slightly as the beneficiary

population in Europe continues to shrink, the military medical facilities in

Europe will not have the capacity to handle all care to eligible

beneficiaries. Nor does it appear practical to staff and maintain enough

military medical facilities to meet the peace-time health care needs of all

eligible beneficiaries. Troops are widely dispersed and, in some places, too

few in number to provide the workload necessary to justify a full service

medical facility and enable medical staff to maintain their skills. Therefore,

beneficiaries’ use of host nation medical care will continue and may

increase.

Given these circumstances, the U.S. military medical leadership needs to

continue to take an active role in attending to and managing the health

care needs of beneficiaries—particularly those who must rely on host

nation care. An active military role not only will ensure that beneficiaries

receive appropriate care but should also improve the perceptions that

beneficiaries have about host nation health care.

DOD has been slow to address the problems confronting military

beneficiaries. In our view, though, the steps that have been taken are

directed toward alleviating the major concerns of most beneficiaries.

Because of these actions, we are not making any recommendations.

Agency Comments In a letter dated June 20, 1995, the Assistant Secretary of Defense (Health

Affairs) generally concurred with this report. (See app. III.) The letter

acknowledged that we accurately described the problems and the

corrective actions under way and planned. In addition, DOD officials

provided updated information on some of the actions they are taking, and

this has been added to the report.

We are sending copies of this report to the Chairman and Ranking

Minority Member, Senate Committee on Armed Services; the Chairman

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and Ranking Minority Member, Subcommittee on Military Personnel,

House Committee on National Security; the Secretary of Defense; and

other interested parties.

This work was performed under the direction of Stephen Backhus,

Assistant Director. Other major contributors were Timothy Hall and Barry

DeWeese. Please contact me on (202) 512-7101 if you have any questions

about this report.

Sincerely yours,

David P. Baine

Director, Federal Health

 Care Delivery Issues

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Contents

Letter 1

Appendix I 

Scope and

Methodology

18

Appendix II 

U.S. Military Medical

Facilities in Germany

and Northern Italy

20

Appendix III 

Comments From the

Department of

Defense

22

Abbreviations

CHAMPUS Civilian Health and Medical Program of the Uniformed

Services

DOD Department of Defense

MHSS military health services system

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Page 17 GAO/HEHS-95-156 Medical Care Overseas
Appendix I 

Scope and Methodology

To assess how DOD is meeting the needs of beneficiaries overseas as the

number of military personnel and facilities are reduced, we visited the

following 15 military communities: Augsburg, Darmstadt, Frankfurt,

Grafenwoehr, Hanau, Heidelberg, Kaiserslautern, Katterbach, Nuremberg,

Spangdahlem, Stuttgart, Wiesbaden, and Wuerzburg, Germany; and Aviano

and Vicenza, Italy. During these visits we met with numerous military

health officials, including the commanders of the of the five remaining U.S.

military hospitals in Germany and northern Italy (four Army and one Air

Force). In addition, we interviewed 29 physicians representing

obstetrics/gynecology, family practice, pediatrics, orthopedics,

allergy/immunology, psychiatry, ambulatory patient care, internal

medicine, radiology, otolaryngologists, and general surgery. We also met

with 11 Army and Air Force commanders and staff of outlying health

clinics.

Because beneficiaries indicated concerns over a lack of access to U.S.

dental facilities overseas, we interviewed six Army dental commanders,

including three Army dental clinic commanders assigned to outlying

military communities.

We conducted “round-table” panel discussions to obtain input from

beneficiaries as to changes in the availability of health care. We convened

20 panels with a total of 102 beneficiaries in the military communities we

visited in Europe. Most of the beneficiaries were active duty members and

their dependents. The beneficiaries were not randomly selected but were

identified by representatives of the National Military Family Association,

Army Community Services, and Air Force Family Support Centers. These

meetings with (1) military medical and dental staff and (2) beneficiaries

provided the basis for much of the information contained in this report.

Both before and after our visit to Europe, we met with officials of the

Office of the Assistant Secretary of Defense (Health Affairs) and Offices of

the Surgeons General to discuss the status of their actions and plans to

meet the health care needs of beneficiaries overseas. In addition, we met

with representatives of the National Military Family Association—an

advocacy group for military families—to discuss their concerns about

military and host nation health care in Europe.

We reviewed documents obtained from military medical officials in the

Office of the Assistant Secretary of Defense (Health Affairs), Offices of the

Surgeons General, and various medical activities in Europe. These

documents included legislation, policy memorandums, medical drawdown

Page 18 GAO/HEHS-95-156 Medical Care Overseas
Appendix I 

Scope and Methodology

information, data on beneficiary access to care, data on military medical

staffing in Europe, analyses of beneficiary complaints, and beneficiary

handbooks about military and host nation medical care.

We did our work between March 1994 and March 1995 in accordance with

generally accepted government auditing standards.

Page 19 GAO/HEHS-95-156 Medical Care Overseas
Appendix II 

U.S. Military Medical Facilities in Germany

and Northern Italy

The following is a list of all U.S. Air Force and U.S. Army medical facilities

operating in Germany and northern Italy as of April 21, 1995. Air Force

facilities are noted with an asterisk.

Hospitals Bitburg, GM*

Heidelberg, GM

Landstuhl, GM

Wuerzburg, GM

Vicenza, IT

Clinics Geilenkirchen, GM*

Ramstein, GM*

Rhein Main, GM*

Sembach, GM*

Spangdahlem, GM*

Aviano, IT*

Augsburg, GM

Babenhausen, GM

Bad Aibling, GM

Bad Kreuznach, GM

Bamberg, GM

Baumholder, GM

Buedingen, GM

Butzbach, GM

Darmstadt, GM

Dexheim, GM

Friedberg, GM

Giebelstadt, GM

Grafenwoehr, GM

Hanau, GM

Hohenfels, GM

Illesheim, GM

Kaiserslautern, GM

Karlsruhe, GM

Katterbach, GM

Kitzingen, GM

Mannheim, GM

Nuremberg, GM

Sandhofen, GM

Schweinfurt, GM

Page 20 GAO/HEHS-95-156 Medical Care Overseas
Appendix II 

U.S. Military Medical Facilities in Germany

and Northern Italy

Stuttgart, GM

Vilseck, GM

Wiesbaden, GM

Livorno, IT

Page 21 GAO/HEHS-95-156 Medical Care Overseas
Appendix III 

Comments From the Department of Defense

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