Military Personnel: Top Management Attention Is Needed to Address Long-standing Problems with Determining Medical and Physical Fitness of the Reserve Force
Published: 2005-10-27T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Defense's (DOD) operations in time of war or national emergency depend on sizeable reserve force involvement and DOD expects future use of the reserve force to remain high. Operational readiness depends on healthy and fit personnel. Long-standing problems have been identified with reserve members not being in proper medical or physical condition. Drilling members in the reserve force by law are required to have a medical exam every 5 years and an annual certificate of their medical status. Also, DOD policies require an annual dental exam and an annual evaluation of physical fitness. Compliance with these routine requirements is the first step in determining who is fit for duty. Public Law 108-375 required GAO to study DOD's management of the health status of reserve members activated for Operations Enduring Freedom and Iraqi Freedom. GAO assessed DOD's (1) ability to determine reserve force compliance with routine exams, and (2) visibility over reserve members' health status after they are called to duty and the care, if any, provided to those deployed with preexisting conditions.
section_title: What GAO Found
paragraphs: DOD is unable to determine the extent to which the reserve force complied with routine examinations due to lack of complete or reliable data. Although each reserve component employs a tracking system capable of monitoring compliance with medical exams, only one component has taken the necessary quality assurance steps to ensure the reliability of its data. While the Office of the Under Secretary of Defense for Personnel and Readiness has the responsibility for overseeing medical and physical fitness policy and processes, it has not established a management control framework and executed a plan to oversee compliance with routine examinations. Specifically, this office has not enforced holding all responsible levels accountable, ensuring that all requirements are being met, and that complete and reliable data are being entered into the appropriate tracking system. For example, this office has not enforced its own requirement for the services to report on the components' physical fitness status. Without complete and reliable data, DOD is not in a sound position to provide the Secretary of Defense or Congress assurances that the reserve force is medically and physically fit when called to active duty. DOD has only limited visibility over the health status of reserve members after they are called to duty and is unable to determine the extent of care provided to those members deployed with preexisting medical conditions despite the existence of various sources of medical information. The components collect various types of medical data, but vary in their ability to systematically identify, track, and report information on those with temporary and permanent conditions that may limit deployability. In addition, medical information is captured on predeployment forms for all members and entered into a DOD-wide centralized database. GAO has previously reported that the database has missing and incomplete health data, and DOD is working to correct this through its quality assurance program. GAO found during this review that DOD has continued to make progress entering the data from the forms into the database, but the data are still incomplete and the reasons why members are determined medically nondeployable are not captured in a way that is easily discernable. While the Under Secretary of Defense continues to have responsibility for overseeing the medical and physical fitness of reserve members after they are called to duty, the combatant commanders, under the Joint Chief of Staff, have this responsibility for the theater. DOD is unable to determine the care provided to those deployed with preexisting medical conditions because DOD has not determined what preexisting conditions may be allowed into a specific theater and, thus, does not know what conditions to track. Evidence GAO developed suggests that members are deployed into theater with preexisting conditions, such as diabetes, heart problems, and cancer. The impact of those who are not medically and physically fit for duty could be significant for future deployments as the pool of reserve members from which to fill requirements is dwindling and those who have deployed are not in as good health as they were before deployment.

section_title: Letter
paragraphs: The Department of Defense’s (DOD) operations in time of war or national  emergency are currently dependent upon sizeable National Guard and  Reserve involvement and DOD expects future use of the reserve force to  remain high. DOD policy acknowledges the importance that reserve  component members are medically and physically fit for deployment  when called to active duty. As of June 2005, more than 323,000 reserve  component members had deployed in support of Operation Enduring  Freedom and Operation Iraqi Freedom, which is almost three times the  number of reserve component members deployed in support of Operations  Desert Shield and Desert Storm. Reserve forces played a vital role in  Operations Desert Shield and Desert Storm. However, problems were  revealed with reserve component members not being in proper medical or  physical condition for these deployments. Some members could not  deploy to the Persian Gulf, and others had difficulty performing their  missions while there. In an effort to help obviate similar problems in the  future, Congress passed legislation during the 1990s to help monitor and  track the health status of deployed members of the Armed Forces,  including reserve component members.
Public Law 108-375, the Ronald W. Reagan National Defense Authorization  Act for Fiscal Year 2005, requires GAO to study DOD’s management of the  health status of reserve component members ordered to active duty in  support of Operation Enduring Freedom and Operation Iraqi Freedom.  Specifically, GAO assessed: (1) DOD’s ability to determine the reserve  components’ compliance with routine medical and physical fitness  examinations, and (2) DOD’s visibility over reserve components’ health  status after they are called to duty and the care, if any, provided to those  deployed with preexisting conditions.
To address our first objective, we reviewed federal statutes and Office of  the Secretary of Defense (OSD) applicable directives and instructions to  identify and understand the roles and responsibilities of the offices within  DOD for management of the health status of the reserve components. We  discussed these statutes and guidance with senior officials in the Office of  the Under Secretary of Defense for Personnel and Readiness. We  discussed service policies for medical and physical fitness with military  officials within the service surgeon general offices and officials  responsible for physical fitness in the service personnel and operations  functions. We also analyzed reserve component regulations and policies  and discussed these with responsible reserve component officials. We  took steps to assess the reliability of these reserve component compliance  data and we discuss the results of our assessment in the report. We also  visited several unit-level commands in all six reserve components. In  addition, we conducted a limited medical and personnel file review and  group discussions at an Army National Guard unit in the Mid-Atlantic and  an Army Reserve unit in the Mid-west for the purposes of understanding  some of the issues confronting the Army components in terms of  compliance.
To address our second objective, we interviewed reserve component  headquarters officials and active component officials responsible for  mobilizing the reserve components and observed an Army mobilization of  Army National Guard and Army Reserve members at Fort Bliss, Texas to  obtain information on processes used to screen members for their medical  deployability. We obtained and analyzed data provided on medical  deployability from DOD’s centralized database on pre- and  postdeployment health assessments, maintained at the Army Medical  Surveillance Activity (AMSA) and discussed available data with AMSA  officials. We also obtained and analyzed data on Army reserve component  members held at mobilization stations for medical reasons and discussed  these data with officials from the Office of the Assistant Secretary of the  Army for Manpower and Reserve Affairs and the Army Office of the  Surgeon General. Based on our review of the AMSA database we used, we  determined that the data from it were reliable for the purposes of this  report. To address the extent of medical care provided in theater for  preexisting medical conditions, we reviewed the Joint Chiefs of Staff  policy for Deployment Health Surveillance and Readiness and information  provided by the U.S. Central Command (CENTCOM) Surgeon General  office regarding medical deployment criteria for Operation Enduring  Freedom and Operation Iraqi Freedom and discussed these policies with  the appropriate DOD officials. We met with medical officials who served in  theater and discussed situations they witnessed related to reserve  members who had deployed with preexisting conditions. We conducted  our review from October 2004 through September 2005 in accordance with  generally accepted government auditing standards. A more thorough  description of our scope and methodology is provided in appendix I.
subsections: section_title: Background
paragraphs: As required by law, each reserve component is to make available qualified  personnel for active duty in the armed forces in time of war or national  emergency and at such other times as national security requires. With this  requirement comes the responsibility that each reserve component  provides personnel who are medically and physically fit for active duty. As  noted in DOD guidance, fitness specifically includes the ability to  accomplish the task and duties unique to a particular operation, and ability  to tolerate the environmental and operational conditions of the deployed  location, including wear of protective equipment.
subsections: section_title: Reserve Components and Routine Medical and Physical Fitness Examinations
paragraphs: DOD reserve components include the Army Reserve, the Army National  Guard, the Air Force Reserve, the Air National Guard, the Navy Reserve,  and the Marine Corps Reserve. Reserve forces consist of three categories:  the Ready Reserve, the Standby Reserve, and the Retired Reserve. The  Ready Reserve had approximately 1.1 million National Guard and Reserve  members at the end of fiscal year 2004, and its members were the only  reservists who were subject to involuntary mobilization under the partial  mobilization authorized by President Bush following the attacks of  September 11, 2001. Within the Ready Reserve, there are three  subcategories: the Selected Reserve, the Individual Ready Reserve, and the  Inactive National Guard. Members of all three subcategories are subject to  a mobilization under a partial mobilization but routine medical and  physical fitness policies apply primarily to the Selected Reserve, consisting  of about 850,000 members at the end of fiscal year 2004.
DOD administers medical examinations to military personnel for various  reasons at different intervals. These include examinations at accession,  mobilization, for special duty assignments, and at separation and  retirement. The examinations that are required routinely for Selected  Reserve members to ensure ongoing medical and physical fitness include  two that are prescribed by federal statute and the second two prescribed  by DOD regulations and policy. Compliance with these routine  requirements is the first step toward determining who is fit for duty.
Federal statute prescribes that each member of the Selected Reserve  who is not on active duty is required to:    be examined as to the member’s physical (medical) fitness every 5 years,  or more often as the respective Secretary considers necessary; and    complete an annual certificate of medical condition.
DOD policy prescribes that each member of the Selected Reserve:  receive an annual dental examination; and    be evaluated annually for physical fitness for duty, to include an  assessment of aerobic capacity, muscular strength, muscular endurance,  and desirable fat composition.
section_title: Reserve Components Differ in Approaches to Mobilize and Medically Screen Members for Deployment
paragraphs: Within the constraints of the existing mobilization authorities and DOD  guidance, the services have flexibility as to how, where, and when they  conduct mobilization processing. As a result, the services differ in how  they mobilize and consequently medically screen members upon  notification that a unit or individual will be called to active duty. The Army  and Navy use centralized approaches, mobilizing their reserve component  forces at a limited number of locations. The Army uses 15 primary sites  that it labels “power projection platforms” and 12 secondary sites called  “power support platforms.” The Navy has 15 geographically dispersed  Navy Mobilization Processing Sites but is currently using only 5 of these  sites because of the relatively small numbers of personnel who are  mobilizing.
By contrast, the Air Force uses a decentralized approach, mobilizing its  reserve component members at their home stations—135 for the Air Force  Reserve and 90 for the Air National Guard—where all medical screening is  performed. The Marine Corps uses a hybrid approach. It has five  Mobilization Processing Centers to centrally mobilize individual reservists  and is currently using three of these centers. However, the Marine Corps  uses a decentralized approach to mobilize its units. Selected Marine Corps  Reserve units do most of their mobilization processing at their home  stations, including medical screening, and then report to their gaining  commands.
section_title: Roles and Responsibilities for Developing and Implementing Examination Requirements
paragraphs: Within the Office of the Under Secretary of Defense for Personnel and  Readiness, the Office of the Assistant Secretary of Health Affairs is  responsible for developing medical policies and processes; the Principle  Deputy to the Under Secretary oversees the Office of Morale, Welfare, and  Recreation for developing physical fitness policies; and the Office of the  Assistant Secretary for Reserve Affairs serves in an advisory capacity to  the Under Secretary to determine how the reserve components can better  implement these requirements. Each service’s Assistant Secretary for  Manpower and Reserve Affairs provides force management policy for both  the active and reserve components. It is then the responsibility of each  National Guard and Reserve Command—the Chief, Army Reserve, the  Director of the Army National Guard, the Chief of the Navy Reserve  (Commander of Navy Reserve Forces and Commander of Marine Corps  Reserve Forces), Chief of the Air Force Reserve, and the Director of the  Air National Guard—that the policies for medical and physical fitness  examinations are properly implemented for their respective commands.  Each National Guard and Reserve unit commander is responsible for  ensuring that the members under his or her command are provided routine  medical and physical examinations in a timely manner, and for identifying  and processing members who are not medically qualified or physically fit  for active duty. The reserve component member is responsible for meeting  scheduled medical examination requirements, obtaining any  recommended follow-up medical and dental care from his or her personal  (civilian) medical provider, and truthfully reporting any changes in his or  her medical or dental condition to military unit commanders and military  medical personnel. Upon mobilization, responsibility for the medical and  physical fitness of the reserve component members transfers to the active  duty counterparts.
section_title: Problems Identified with Medical Deployability during Operations Desert Shield and Desert Storm
paragraphs: Several studies identified medical issues with the reserve component  members called to duty for Operations Desert Storm and Desert Shield. A  1991 Army Inspector General report estimated that as many as 8,000  reserve component personnel were found to be medically nondeployable  upon arrival at mobilization stations. Even though all but 1,100 eventually  deployed, the nondeployable soldiers disrupted the mobilization process  because units had to undergo extensive efforts to replace nondeployable  reserve members with those who could be deployed. The report also noted  that some soldiers who had coronary bypass surgery, cancer, and  amputations had not been identified at their home stations and reported to  their mobilization station. In 1991, we reported that medical screenings  conducted at mobilization stations identified numerous problems that  impaired soldiers’ ability to deploy, including ulcers, chronic asthma,  spinal arthritis, hepatitis, seizures, and diabetes. In 1992, we reported that  because many medical personnel were found nondeployable for various  reasons, including medical reasons, many units deployed with medical  personnel shortages and were not fully mission capable upon arrival in the  Persian Gulf. For example, two reserve component surgeons—one who  was unable to stand for more than 30 minutes and another who had  Parkinson’s disease—reported for duty but were unable to deploy due to  their conditions. A 1992 Sixth U.S. Army Inspector General report stated  that many soldiers deployed to Southwest Asia had to return to the United  States because of medical conditions that had not been previously  diagnosed. This report noted that home unit commanders were not  identifying soldiers with severe medical problems, some permanent, to  determine if they were medically fit to perform their duties and job  assignments before deploying.
In 1994, we did a comprehensive review of the medical and physical  fitness policies for reserve component members serving in Operations  Desert Storm and Desert Shield and found that at one Army mobilization  station nearly 4 percent of the reserve component members reporting for  duty had serious medical conditions including cancer and heart disease.  One soldier had double kidney failure, one had muscular dystrophy, and  another had a gunshot wound to the head. We found that DOD medical  policy, which permits the services to retain nondeployable reservists, was  inconsistent with a military strategy that requires forces to be capable of  responding quickly to unexpected military contingencies anywhere in the  world and we recommended that DOD revise its policy that allows  members not to be worldwide deployable, but DOD disagreed and did not  take action. We also found that DOD was not aware of the physical fitness  problems because the services were not reporting fitness information as  DOD required and GAO recommended that DOD revise its directive to  require services to report on their members’ physical fitness status. DOD  concurred with our recommendations and agreed to take actions. Other  related GAO products are found at the end of this report.
section_title: DOD’s System to Assess Active and Reserve Component Members’ Health Status Prior to Deployments
paragraphs: Section 1074f of Title 10, United States Code requires that the Secretary of  Defense establish a system to assess the medical condition of members of  the armed forces (including members of the reserve components) who are  deployed outside of the United States or its territories or possessions as  part of a contingency operation or combat operation. It further requires  that records be maintained in a centralized location to improve future  access to records, and that the secretary establish a quality assurance  program to evaluate the success of the system in ensuring that members  receive pre- and postdeployment medical examinations and that record- keeping requirements are met.
DOD policy requires that the services collect pre- and postdeployment  health information from their members, and submit copies of the forms  that are used to collect this information to the Army Medical Surveillance  Activity (AMSA). Initially, deployment health assessments were required  for all active and reserve component personnel who were on troop  movements resulting from deployment orders of 30 continuous days or  greater to land-based locations outside the United States that did not have  permanent U.S. military treatment facilities. However, on October 25,  2001, the Assistant Secretary of Defense for Health Affairs updated DOD’s  policy and required deployment-related health assessments for all reserve  component personnel called to active duty for 30 days or more. The policy  specifically stated that the assessments were to be done “whether or not  the personnel were deploying outside the United States.” Both  assessments use a questionnaire designed to help military healthcare  providers in identifying health problems and providing needed medical  care. The predeployment health assessment is generally administered at  the service mobilization site or unit home station before deployment.
On February 1, 2002, the Chairman of the Joint Chiefs of Staff issued  updated deployment health surveillance procedures. Among other things,  these procedures specified that active and reserve component personnel  must complete or revalidate the health assessment within 30 days prior to  deployment. The procedures also stated that the original completed health  assessment forms were to be placed in the military member’s permanent  medical record and a copy “immediately forwarded to AMSA.”
Both forms include demographic information about the servicemember,  member-provided information about the member’s general health, and  information about referrals that are issued when service medical providers  review the health assessments. The predeployment assessment also  includes a final medical disposition that shows whether the member was  deployable or not.
In September 2003, we reported that DOD did not maintain a complete,  centralized database of the active Army and Air Force components’  member health assessments and immunizations. Following our 2003  review, DOD established a deployment health quality assurance program  to improve data collection and accuracy. The department’s first annual  report documenting issues relating to deployment health assessments was  issued in May 2005.
In September 2004, we reported similar findings for the reserve  component members. We reported that DOD’s ability to effectively  manage the health status of its reserve component members is limited  because its centralized database has missing and incomplete health  records and it has not maintained full visibility over reserve component  members with medical problems. For example, the Marine Corps did not  send predeployment health assessments to DOD’s database as required,  due to unclear guidance and a lack of compliance monitoring. The Air  Force has visibility of involuntarily mobilized members with health  problems, but lacks visibility of members with health problems who are on  voluntary orders. As a result, some Air Force reserve component  personnel had medical problems that had not been resolved for up to 18  months, but the full extent of this problem was unknown since the Air  Force did not have a mechanism for tracking members who are on  voluntary duty orders with medical problems. We made several  recommendations regarding improvements in this area and DOD generally  concurred with our recommendations and agreed to take actions.
section_title: Recent DOD Efforts in Response to the 2005 National Defense Authorization Act
paragraphs: Section 731 of the Ronald W. Reagan National Defense Authorization Act  for Fiscal Year 2005 (NDAA) requires the Secretary of Defense to develop  and implement a comprehensive plan to improve medical readiness of  members of the Armed Services by focusing on areas such as health  status, health surveillance, and accountability for medical readiness. The  mandate also required that the Secretary of Defense establish a Joint  Medical Readiness Oversight Committee (JMROC) with a specified  membership to oversee the development and implementation of a  comprehensive medical readiness plan.
In response to the act, the first meeting of the JMROC was held in  February 2005 during this review. The committee is chaired by the Under  Secretary of Defense for Personnel and Readiness and membership  includes the Assistant Secretaries of Defense for Reserve Affairs and  Health Affairs, the Joint Staff Surgeon, the Chief of the National Guard  Bureau, Army Reserve, Navy Reserve, Air Force Reserve and the  Commander of the Marine Corps Reserve, as well as the Vice Chiefs of  Staff of the Army, Vice Chief of Navy Operations, the Vice Chief of Staff of  the Air Force and the Assistant Commandant of the Marine Corps as well  as their respective Surgeon Generals and Assistant Secretaries for  Manpower and Reserve Affairs, and a representative of the Department of  Veterans Affairs.
A draft copy of the Comprehensive Medical Readiness Plan which  addresses all defense medical issues identified in the act was signed by the  Under Secretary of Defense for Personnel and Readiness on June 23, 2005.  Officials from the Force Health Protection Directorate in the OSD Office  of Health Affairs—which is providing the staff for drafting and overseeing  this effort—stated that financial and legislative constraints, which may  limit the implementation of the plan, will have to be identified and  addressed, and indicators for measuring progress will have to be  developed before the plan is finalized.
Among other things, the draft plan specifies that DOD:  (l) institutionalize the Individual Medical Readiness (IMR) reporting  process by developing a DOD instruction for the IMR and requires that this  information be provided to commanders to assist them in improving the  health status of members of their units;  (2) expand and improve the pre- and postdeployment assessment process  by refining the predeployment survey to improve consistency with the  postdeployment survey and develop periodic postdeployment health  reassessments;  (3) develop a policy defining the circumstances under which treatment for  medical conditions may be provided in theater and circumstances under  which medical conditions are to be resolved prior to deployment; and  (4) review the results of this GAO study.
section_title: Lack of DOD Oversight Hinders DOD’s Ability to Determine Reserve Components’ Compliance with Routine Medical and Physical Fitness Examination Requirements, but Indications of Noncompliance Exist
paragraphs: DOD is unable to determine the extent to which the reserve components  are in compliance with routine medical and physical fitness examination  requirements primarily due to a lack of OSD guidance, oversight, and  incomplete or unreliable compliance data supplied by the components.  Although the Office of the Under Secretary of Defense for Personnel and  Readiness (OSD/P&R) has the responsibility for overseeing medical and  physical fitness policy and processes, this office has not established a  management control framework and executed a plan to oversee  compliance with routine examinations. For example, OSD/P&R has not  provided guidance to the reserve components regarding requirements for  the 5-year medical examination and an annual medical certificate. Thus, in  the absence of OSD guidance, each reserve component has developed its  own implementing policies, resulting in differences in scope, frequency,  and administration making it difficult because uniform criteria against  which to measure compliance do not exist; however, OSD has provided  consistent guidance for dental and physical fitness examinations. DOD’s  ability to determine the extent of compliance has been hindered because  OSD does not oversee reserve component members’ compliance with the  routine physical fitness or medical examination requirements.  Furthermore, the data reported at the reserve component level have been  incomplete and unreliable for purposes of determining compliance with  routine medical and physical fitness examinations, and responsibility for  compliance has not been enforced. We found indications of  noncompliance during our site visits and reviews of existing audit reports  and investigations. OSD’s lack of oversight could negatively impact  operational readiness for future deployments, as the number of needed  personnel may not be medically and physically fit for active duty.
subsections: section_title: Lack of OSD Guidance Contributes to Variations in Examination Policies among the Components
paragraphs: Although OSD/P&R has the responsibility for overseeing medical and  physical fitness policy and processes, this office has not established a  management control framework and executed a plan that includes issuing  guidance to the reserve components on compliance with the requirements  for the 5-year medical examination and an annual medical certificate. For  example, the statutory requirement for the 5-year medical examination has  not been defined by OSD, leaving each reserve component to develop  implementing guidance, resulting in differences in scope, frequency, and  administration of the examination among the components. In addition,  there has not been any OSD implementing guidance regarding the  statutory requirement for an annual medical certificate, and so different  guidance has been developed by the surgeons’ general offices responsible  for each of the six reserve components. Lack of OSD guidance makes  oversight difficult to determine because the uniform criteria against which  to measure the components’ compliance do not exist. OSD, through the  Office of the Assistant Secretary of Defense for Health Affairs, has  established a consistent requirement and implementation policy for an  annual dental examination. OSD has also established a consistent  requirement for a physical fitness examination, although the specific  content of the physical fitness examination varies among the components  and it is not coordinated with the medical examinations.
subsections: section_title: 5-Year Medical Examination Requirements Vary among the Components
paragraphs: The requirement for a routine medical examination has been in effect for  all active and reserve components since at least 1960. Yet, as of  September 2005, OSD has not developed a plan or provided direction to  the components on how to implement this requirement. In the absence of  OSD guidance, the surgeons general responsible for the four services and  six reserve components have each developed their own separate  implementing guidance for the current requirement for a 5-year medical  examination, resulting in differences in scope, frequency, and  administration among the components as illustrated below.
Routine medical examinations include assessments in six areas: physical  capacity or stamina, upper extremities, hearing and ears, lower  extremities, eyes/vision, and psychiatric. For Army active and reserve  component members older than age 40, there are additional age-specific  screenings such as prostate examination, a prostate-specific antigen test,  and a fasting lipid profile that includes testing for total cholesterol, low- density lipoproteins, and high-density lipoproteins. The Department of the  Navy conducts routine medical examinations on all Navy and Marine  Corps active component and reserve members that include height and  weight measurements, blood pressure testing, urinalysis, serology, and  mental issues. Those being examined are also questioned about their past  and present medical history, including serious illnesses, injuries, chronic  conditions, and operations. The Air Force reserve components’ medical  examination for nonflyers has been significantly reduced to minimize lost  training time due to annual medical requirements. The scope of the  current testing exam requirement is essentially limited to brief skin exams  for scars and cancer and limited laboratory blood work, and excludes  EKGs, cholesterol, lipid panels, depth perception, glaucoma, and  mammograms. One question asked on the questionnaire addresses mental  status and whether the member has a history of anxiety or depression.
In addition to the differing scope, the different implementing guidance  across the services has resulted in variations among the services in the  frequency and administration of the 5-year medical examinations. For  example, Army guidelines require that Selected Reserve members  complete a medical examination once every 5 years. During our review,  the Navy and Marine Corps personnel were examined at slightly different  intervals: every 5 years through age 50, every 2 years through age 60, and  annually after age 60. The Air Force is even more different, in that it no  longer requires a traditional medical examination physical be completed  every 5 years for nonflyers. Instead, members are required to complete an  annual Preventive Health Assessment (PHA), the answers to which— combined with the member’s age, gender, health risk factors, medical  history, and occupations—will determine the types of screening and  laboratory tests required and if the member needs to be seen by a military  health care provider. At a minimum, however, Air Force reserve  component members are required to have a visit with a military health  care provider, or Periodic Health Assessment Monitor (PHAM), at least  once every 3 years, while Air National Guard members are required to visit  a Health Care Provider (HCP) at least once every 5 years. Thus,  differences exist between the two Air Force reserve components.
section_title: Annual Certification of Members Medical Condition Varies among Components
paragraphs: In the absence of any implementing guidance from OSD, guidance for the  annual certification of medical condition has been developed by the  surgeon general’s offices responsible for each of the six reserve  components. Like the 5-year medical examination, the annual certificate of  medical condition is prescribed by statute which states that “each  member of the Selected Reserve who is not on active duty shall execute  and submit annually to the Secretary concerned a certificate of physical  condition.” This requirement has been in law since at least 1960 and is  especially important for the reserve components, since they are not seen  by military health care providers as often as the active duty.
The different guidance from each of the services has resulted in differing  definitions from each service as to what is involved in the annual medical  certificate. For example, Department of Army regulations require that all  members of the Army Reserve and Army National Guard certify their  medical condition annually on a two-page certification form, where  members report physician and dentist visits since their last examination,  describe current medical or dental problems, and disclose any  medications they are currently taking. Navy and Marine Corps Selected  Reserve members complete an Annual Certificate of Physical Condition  that provides information including the location of their health and dental  records, the dates and purpose or type of their last complete physical and  dental examinations, and the date of their last HIV blood test among  others. Reservists are also expected to disclose any injury, illness, or  disease that occurred within the last 12 months and resulted in  hospitalization, or caused them to be absent from work, school, or duty for  more than 3 consecutive days; if they have been under a physician’s care  or taken prescription medications during the past 12 months; and any  physical defects, family issues, or mental problems that would prevent  them from being mobilized. The Air Force has combined this annual  requirement into its PHA screening process. Within the Air Force Reserve,  the PHA process involves all members initially completing a Reserve  Component Health Risk Assessment, which was formerly known as the  Annual Medical Certificate. In the Air National Guard, the PHA involves all  the members initially completing an annual Health History  Questions/Interval History, which was formerly known as the Annual  Medical Certificate.
section_title: Dental Examination Requirements Are Consistent among Components
paragraphs: The annual dental examination is a consistent requirement across the  reserve components that was established by DOD policy and provided  consistent standards for active duty and Selected Reserve members to  improve dental readiness. In 1998, the Office of the Assistant Secretary of  Defense for Health Affairs, under the Under Secretary of Defense for  Personnel and Readiness, directed that all active duty and Selected  Reserve members obtain an annual dental examination so that DOD would  have a clear picture of members’ dental readiness and fitness for duty.  Although the 1998 directive required all services to provide  implementation plans for completing all dental examinations by 2001,  Health Affairs recognized that the services were having difficulty  identifying both the mechanisms for compliance and the tracking system  for documentation, and extended the goal of 90 percent compliance until  February 2004. A year and half later, DOD still does not have complete and  reliable information on all reserve components’ compliance.
According to Army regulation, all soldiers within the Army National Guard  are required to have a dental examination on an annual basis. The current  annual dental examination requires an assessment of the current state of  oral health; risk for future dental disease, including periodontal  assessment; and oral cancer screening. Prior to early 2004, the Army  reserve components were still conducting only a dental screening. In  March 2000, the Navy issued instructions requiring Navy and Marine Corps  reservists to undergo an annual dental examination. Currently, both the  Air Force Reserve and Air National Guard require annual dental  examinations in line with DOD’s requirement. The Air Force Reserve made  this a requirement in January 2003, but the Air National Guard did not  make it a requirement until September 2004. Prior to these times, the  required dental exam interval was once every 3 years for the Air Force  Reserve and once every 5 years for the Air National Guard.
section_title: Physical Fitness Examination Requirements Consistent among the Components, but Content Varies and It Is Not Coordinated with Medical Examination Requirements
paragraphs: Although the specific content of the physical fitness examination varies  among the components, the requirement for at least an annual physical  fitness examination is consistent across the components because it was  established by DOD policy which is to be monitored by the Principal  Deputy Under Secretary of Defense for Personnel and Readiness, Office of  Morale, Welfare, and Recreation. Specifically, the policy requires that all  military services and reserve components develop and use physical fitness  tests that evaluate aerobic capacity (e.g., a timed run), muscular strength,  and muscular endurance (e.g., push-ups, pull-ups, sit-ups), and that all  service members be formally evaluated and tested for the record at least  annually (unless they are under a medical waiver).
The specific content of the physical fitness examination varies among the  components because different physical abilities are needed to meet the  services’ different missions. The Army Physical Fitness Test (APFT) is a  performance test that indicates a member’s ability to perform physically  and handle his or her own body weight. The APFT is required annually for  the Army National Guard. As of October 2004, the Chief of the Army  Reserve required Army reservists to be tested twice a year, as are their  active component counterparts. The APFT consists of 2 minutes of push- ups, 2 minutes of sit-ups, and a 2-mile run (the same test is administered to  both the active and reserve component). The number of push-ups and sit- ups and the 2-mile run time are based on the soldier’s age range and sex  (the physical fitness test required to enter the Army has the same  requirements for all ages, but different requirements for gender). All Navy  personnel, regardless of age and component (active or reserve), are  required to participate semiannually in a Physical Fitness Assessment that  includes a Body Composition Assessment and Physical Readiness Test  unless medically prohibited from doing so. Body composition is assessed  by an initial weight and height screening or an approved circumference  technique to estimate body fat percentage. Testing includes a series of  physical events designed to evaluate an individual’s flexibility through a  sit-reach activity, muscular strength and endurance through curl-ups and  push-ups, and aerobic capacity through a 1.5-mile run/walk, or 500-yard or  450-meter swim. Individuals who fail either the Body Composition  Assessment or the Physical Readiness Test or both are considered to have  failed the entire assessment. The Marine Corps has also developed a Body  Composition Program and Physical Fitness Test to assess each Marine’s  fitness level. Active component Marines are tested semiannually while  Marine Corps Reservists are tested annually. Body composition standards  are health- and performance-based limits for body weight and body fat.  Physical fitness testing includes pull-ups for males, flexed-arm hang for  females, a timed abdominal crunch event, and a timed 3-mile run. These  events are designed to test the strength and stamina of the upper body,  midsection, and lower body, as well as the cardiovascular system. The Air  Force fitness program requires an annual physical assessment to motivate  all members to participate in a year-round physical conditioning program,  including proper aerobic conditioning, strength/flexibility training, and  healthy eating. Fitness assessment results are based on a composite score  calculated from results of an aerobic assessment (1.5-mile run), muscular  fitness assessment (push-ups and crunches), and body composition  measurement (abdominal circumference measurement).
Although DOD has directed the military physical fitness programs to  complement the health promotion program within OSD’s Office of Health  Affairs and senior medical officials have told us that medical and physical  fitness go “hand-in-hand,” physical fitness policies are not coordinated  with medical fitness policies at the OSD, service, reserve component, or  unit levels. Furthermore, DOD did not consider physical fitness a factor  for determining the medical deployability of reserve component members  prior to deployment to Iraq and Afghanistan, even though we reported in  1994 that several Army reports on Operations Desert Shield and Desert  Storm noted fitness-related problems that hindered wartime operations.  For example, one report noted that poor fitness contributed to the deaths  by heart attack of eight reserve component personnel deployed to the  Persian Gulf.
section_title: OSD Does Not Oversee Compliance with Routine Medical and Physical Fitness Examinations
paragraphs: OSD does not have a plan to oversee reserve components’ compliance  with the routine medical or physical fitness examinations, which hinders  DOD’s ability to determine the extent of compliance. For example, OSD  does not track reserve component members’ compliance with routine  medical examinations. In addition, OSD does not enforce its own directive  requiring the services to report on their members’ compliance with  physical fitness examinations.
subsections: section_title: OSD Does Not Track Compliance with Routine Medical Examinations
paragraphs: Although OSD’s Office of Health Affairs has begun to track medical  readiness indicators, it does not have a plan to track compliance with  routine medical examinations and does not attempt to track compliance  with physical fitness examinations. OSD’s Office of Health Affairs has  initiated a process requiring that all reserve components report quarterly  the percentage of their members who are in compliance with the following  six indicators of medical readiness: dental class I or II; immunizations;  medical readiness laboratory tests, such as providing a blood sample; no  deployment-limiting conditions; periodic health assessment; and medical  equipment, such as eyeglass inserts for face masks. This process continues  to evolve as the Office of Health Affairs wrestles with inconsistencies in  requirements among the reserve components, especially in regard to the  periodic health assessment since each reserve component implements the  requirement for a periodic 5-year medical examination differently.  Without centralized oversight and management for tracking compliance,  DOD’s ability to determine the extent of compliance with routine medical  examinations may be impeded.
section_title: OSD Has Not Enforced Its Directive Requiring the Services to Report on Compliance with Physical Fitness Exams
paragraphs: OSD has not enforced its own directive requiring the reserve and active  components to report on their members’ compliance with physical fitness  examinations by March 2005. Although DOD policy states that physical  fitness is a vital element of combat readiness and is essential to the  general health and well-being of military personnel, OSD and the reserve  components have been lax in reporting compliance with physical fitness  examination requirements and do not fully utilize available systems that  could report physical fitness status on a servicewide basis. DOD  established a reporting requirement for physical fitness in November 2002,  in response to recommendations from our prior reports; however, it has  not enforced compliance with this new requirement.
The new physical fitness policy requires that each military service  establish and maintain a data repository that provides baseline statistics  and a tracking mechanism that monitors physical fitness and body fat for  both the active and reserve components. The policy was developed over  the course of many years. In response to a recommendation in our 1994  report, the Under Secretary of Defense for Personnel and Readiness  stated that revised DOD guidance would “require the services to provide  an annual report assessing their physical fitness and health promotion  programs, to include a brief summary on how physically fit and healthy  they view their military members, both active and reserve components.”  Not only did the original directive fail to require the services to submit an  annual report on the status of servicemembers’ physical fitness, but senior  military officials in the office responsible for developing these directives  told us that no service ever submitted a status report on their physical  fitness programs as required by the revised directive. In 1998, we again  reported that DOD’s oversight of the physical fitness program was  inadequate and that DOD had not enforced the annual reporting  requirement. Officials in the Office of Morale, Welfare, and Recreation  stated that in response to our report, DOD guidance was again revised in  November 2002, to require the services to report annually to the Principal  Deputy Under Secretary of Defense for Personnel and Readiness on a  number of very specific physical fitness statistics, including the number of  personnel tested, the number of personnel who failed the test, and the  number placed in remedial training programs. The first report was due to  the Principal Deputy Under Secretary of Defense for Personnel and  Readiness by the military services by March 31, 2005. However, during our  review we were told by officials in the Office of Morale, Welfare, and  Recreation that none of the reports had been submitted to the Principal  Deputy as required. The Air Force, Navy, and Marine Corps were  developing their information during this review. The Army had until March  2007 to report because, according to a signed memorandum by the  Principal Deputy Under Secretary of Defense for Personnel and Readiness,  the Army is taking steps to report this information as part of the Defense  Integrated Military Human Resources System (DIMHRS). Until this  reporting requirement is enforced, DOD’s ability to determine compliance  with the physical fitness examinations may continue to be hindered.
section_title: Reporting of Compliance at Reserve Component Level Is Hindered by Incomplete and Unreliable Data and Lack of Enforcement
paragraphs: Incomplete and unreliable data at the reserve component level regarding  compliance with routine medical and physical fitness examinations have  hindered DOD’s ability to determine the extent of the reserve components’  compliance with the examination requirements. Each reserve component  employs a tracking system capable of monitoring compliance with medical  examinations, but only one reserve component—the Navy Reserve—has  data that are reliable for determining compliance with routine medical  examinations. Furthermore, even though DOD policy calls for each  military service to establish and maintain a physical fitness data  repository, no reserve component has demonstrated that its tracking  system can report complete and reliable compliance data on physical  fitness. Although the reserve components place the responsibility for  tracking compliance with medical and physical fitness examinations on  the unit commander, the reserve components do not always hold the unit  commanders accountable and the unit commanders do not always enforce  the compliance of their members. No centralized oversight exists to hold  all levels accountable, thus ensuring that all requirements are being met.
subsections: section_title: Most Reserve Component Data on Compliance with Routine Medical Examinations Are Unreliable
paragraphs: All of the reserve components are now employing systems that can track  compliance with medical examinations, but only one reserve component— the Navy Reserve—has taken the necessary quality assurance steps to  ensure the reliability of its data on compliance with routine medical  examinations. In contrast, we found that the data captured by the systems  used by the Army and the Air Force were unreliable for determining  compliance with routine medical examinations. We did not assess the  reliability of the data used by the Marine Corps because it is in the process  of implementing and testing the use of the Navy’s system.
Assessing data for their reliability includes quality assurance steps to  consider the completeness and currency of the data, i.e., determining  whether there are assurances that all members are included and the  information is up to date; quality control measures, such as conducting  periodic testing of the data against medical records, to ensure the  accuracy and reliability of the data; and examining who is using the data  and for what purposes, and how reliable the user thinks the data are. We  found that the Navy Reserve had taken such quality assurance steps. For  example, the Navy has directed its Readiness Commands to conduct  routine inspections to verify medical data accuracy in the Navy Reserve’s  Medical Readiness Reporting System (MRRS) and required reserve units to  review 10 percent of their medical records for accuracy after each drill  weekend. In addition, Navy Reserve units are also required to keep the  Commander, Navy Reserve Forces Command informed about medical and  dental compliance on a biweekly basis.
In contrast, we found that the compliance data on routine medical  examinations captured by the Army Medical Protection System  (MEDPROS) were unreliable for the purposes of determining compliance  with routine medical examinations. MEDPROS was developed in 1998 to  track anthrax compliance and has since matured to meet current  mobilization requirements. All Army components—active, reserve, and  guard—are required to enter members’ medical compliance data into  MEDPROS. We found the data captured by this system are unreliable for  monitoring compliance with routine requirements for several reasons,  including missing data, failure to include data for all Army units, and lack  of quality assurance assessments on data content being performed to test  the data’s reliability. Until quality control measures are instituted, the  Army will not be able to reliably use MEDPROS to track compliance with  the requirements for the 5-year medical examination, the annual medical  certificate, and the annual dental examination.
We also found that the Air National Guard’s Preventive Health Assessment  and Individual Medical Readiness (PIMR) system and the Air Force  Reserve’s Reserve Component Periodic Health Assessment (RCPHA)  system were unreliable for the purposes of determining compliance with  routine medical examinations. We found that neither system produces  data that are reliable for the purposes of determining compliance with  routine medical examinations because: (1) both the Air Force Audit  Agency and Air Force Inspection Agency have reported discrepancies in  their review of medical records and the data from these systems, and   (2) there is a high reliance on unit commands to test and verify the  reliability of the data. In addition, during our site reviews, we found  medical staff at several commands having difficulty entering large  backlogs of medical data, which raised concerns about the timeliness of  the data. Often, this backlog took several weeks to resolve and required  the assistance of full-time reservists. However, according to program  managers and database administrators, the quality of the data, in terms of  their completeness and accuracy, ranges from quite good to exceptional  when subjected to internal system software checks. Until resources  necessary to input and verify the data in a timely manner are provided, the  Air Force will not be able to rely on PIMR and RCHPA data to determine  compliance with routine medical examination requirements.
We did not assess the reliability of the data used by the Marine Corps  because it is in the process of implementing and testing the use of Navy’s  system. According to a Marine Corps official, once the new system is fully  implemented, the Marine Corps will have the same oversight capability  over medical compliance that the Navy Reserve currently has.
section_title: Reserve Components Are Unable to Report Complete and Reliable Data on Compliance with Routine Physical Fitness Examinations on a Componentwide Basis
paragraphs: Even though DOD policy calls for each military service to establish and  maintain a physical fitness data repository, no reserve component has a  tracking system that can report complete and reliable data on compliance  with physical fitness examinations on a componentwide basis. In fact, the  Army Reserve, the Army National Guard, and the Marine Corps Reserve do  not have systems that are designed to track compliance with physical  fitness examinations on a componentwide basis.
The Navy Reserve, the Air National Guard, and Air Force Reserve each  have systems that can track compliance with physical fitness  examinations on a componentwide basis. The Navy Reserve system,  however, may not be producing reliable data at this time. Further, we have  concerns regarding the reliability of the data produced by the Air National  Guard and the Air Force Reserve because such data are not reviewed or  validated on a regular basis.
The Army does not report physical fitness on a componentwide basis.  According to a Department of Army memo, dated April 19, 2004, and  confirmed through our discussions with Army and OSD officials, physical  fitness and body composition data will eventually be tracked in DIMHRS,  in which the Army is the first component to participate. Until DIMHRS is  used, the Army will be unable to report complete and reliable data on  componentwide compliance with the physical fitness examination  requirements. According to Army Reserve officials, physical fitness data  can be tracked in the regional level application software database, but the  information may not be updated by the units in a timely or consistent  manner. This information is then updated in the Total Army Personnel  database, which updates the Individual Training and Readiness System. In  the Army National Guard, the states may use the personnel database to  record the scores and dates of physical fitness examinations, but not  consistently. The Army’s first report on the status of its physical fitness  compliance for all its components will be due March 31, 2007, because the  Office of the Under Secretary of Defense for Personnel and Readiness  granted the Army a 2-year extension for its requirement to report on the  physical fitness status of all members (active, reserve, and guard). The  data in this report, if complete and reliable, could enable DOD to  determine the Army’s compliance with the physical fitness examination  requirement. According to the 2004 Department of the Army Memo, if  DIMHRS is not on line by September 2006, the Army will manually report  these data.
Compliance with physical fitness examination requirements is tracked at  headquarters level for the Navy Reserve, but we found that the Navy is  unable to report complete and reliable compliance data. The Navy requires  all commands to report their physical fitness assessment data, including  physical readiness test results, through the Physical Readiness  Information Management System (PRIMS). However, we found the data  generated by this system to be unreliable because, according to a Navy  Official, there are about 2,000 duplicate records that need to be purged  and about 25 percent of the Body Composition Assessment scores have  not been reported by unit commanders. Until internal controls are  established to eliminate duplication and ensure completeness of data, the  Navy will be unable to report complete and reliable data on  componentwide compliance with the physical fitness examination  requirement. The Navy submitted its annual report on physical fitness, due  March 31, 2005, to DOD 3 months late, on July 8, 2005. According to a DOD  official, the Navy did not request an extension or provide an explanation  for the late submission. Because the data in this report came from the  PRIMS system that we found to be unreliable, we do not believe that DOD  can reliably use the information in the report to determine the Navy’s  compliance with the physical fitness examination requirement.
The Marine Corps is unable to report complete and reliable data on  compliance with the physical fitness examination because, in contrast to  the Navy, the Marine Corps does not have a dedicated physical fitness  reporting system. Instead, the Marine Corps requires unit commanding  officers to record physical fitness scores in unit diaries, personnel records,  and the Marine Corps Total Force System, a Marine Corps-wide personnel  system. Units that input data into this system are responsible for reviewing  the data and certifying that they are correct. However, a Marine Corps  official indicated that the data are assumed to be correct when transmitted  to higher commands, but no steps are taken to verify accuracy of the data.  As of August 2005, the Marine Corps had provided DOD with a draft report  addressing calendar year 2004 physical fitness scores. According to a DOD  official, the Marine Corps did not request an extension or provide an  explanation for the late draft submission. Further, as of September 2005,  the Marine Corps had not responded to our official request for the annual  physical fitness report. Without an ongoing quality assurance program to  consistently and continuously ensure the completeness and reliability of  the data in the Marine Corps Total Force System, we did not rely on the  data in the draft Marine Corps Physical Fitness Report provided to DOD.
Although both the Air Force Reserve and Air National Guard each have a  dedicated system to track the physical fitness status of their members, we  found quality assurance procedures lacking, possibly leading to  incomplete and unreliable data with which to track physical fitness  compliance. The Air Force Reserve’s software system Program—the Air  Force Fitness Management System (AFFMS)—only tracks fitness program  results on a current basis and only retains data entered from 2004 forward.  However, quality assurance procedures are not followed. For example,  there are delays in entering data; compliance of individual units is only  reviewed if there is a question; and headquarters does not routinely assess  members’ currency. This program relies on a fitness program manager  within each unit command to monitor program metrics. According to an  AFFMS system official, the only true way of determining the reliability of  the data in this system is to compare these data with the data in the  respective member’s personnel files, and this has not been done. The Air  National Guard (ANG) tracking system for compliance with physical  fitness examinations is ANG’s Fitness Age and was first implemented in  late 2003, although many ANG units lagged in their use of Fitness Age until  after April 2004. ANG’s Fitness Age database only reflects calendar year  information as of a specific point in time, and does not track or measure  performance based on a running 12-month period. The ANG Fitness  Program requires an assessment on all ANG members once per calendar  year. According to ANG officials, most physical fitness testing is  performed within the last few months of the calendar year. Because the  data are cumulative, the only time that physical fitness information can be  assessed for all members taking the test is at the end of the calendar year.  In other words, most reservists would appear out of compliance until they  take their annual exam even though they are probably still within their 1- year window for testing. Furthermore, information on the number of  reservists not tested at all or who are overdue is not captured by the ANG  Fitness Age database. According to an ANG official, the responsibility for  managing the physical fitness program rests with the respective ANG  installation’s command. The respective ANG installations (unit  commands) have visibility over their respective “overdue” members.  However, ANG headquarters lacks sufficient oversight to assess  compliance. Without ongoing quality assurance programs to consistently  and continuously ensure the completeness and reliability of the data in the  Air National Guard and Air Force Reserve systems, we did not rely on the  data in these systems.
section_title: Accountability to Comply with Routine Medical and Physical Fitness Examination Is Not Always Enforced
paragraphs: In general, throughout the reserve components, the individual members  are responsible for maintaining their physical and medical fitness and the  unit commanders are responsible for ensuring members’ compliance with  medical and physical fitness examinations; however, the reserve  components do not always hold the unit commanders accountable and the  unit commanders do not always enforce the members’ compliance.  Accountability for compliance is fragmented at various levels of command.  No centralized oversight exists to hold all levels accountable ensuring that  all requirements are being met. Individual members are responsible for  attending all scheduled examinations and assessments, seeking timely  medical advice when necessary, reporting changes in their medical health  on the annual medical certificate, and successfully completing the  requirements of the physical fitness examinations. False statements may  result in reassignment, discharge, or other disciplinary action. Unit  commanders are responsible for implementing any administrative and  command provisions for examinations, informing members of the  examination requirements, establishing training programs for physical  fitness, taking actions against reserve members who fail to comply with  the requirements, and reporting the current medical and dental status of  reservists through the applicable tracking systems, and they are ultimately  responsible for the accuracy of medical and physical fitness information  relied on by higher commands. However, reserve components do not  always hold the unit commanders accountable for these responsibilities  and the unit commanders we interviewed expressed concern about the  many competing responsibilities they have, such as meeting training  requirements, and how they must prioritize the use of their limited  resources. One unit commander also expressed concern about enforcing  medical and physical fitness policies if it meant losing a “good soldier”  who otherwise performs his duties well. Without oversight and  accountability at the OSD and respective service and reserve component  levels, unit commanders may not have the incentive or resources to fully  enforce the medical and physical fitness examination requirements and  compliance may suffer.
section_title: Indications of Noncompliance with Medical and Physical Fitness Examination Requirements Exist
paragraphs: Although DOD can not determine the extent of reserve components’  compliance with routine medical and physical fitness examinations, we  found indications of noncompliance during our site visits and in our  reviews of existing audit reports and investigations. For example, a limited  review of medical files at one Army National Guard and one Army Reserve  location, data from a Navy report, test results of two units in a Marine  Corps battalion, and data from a review conducted by the Air Force Audit  Agency indicate some noncompliance at all components with the routine  medical examination, annual medical certificate, annual dental  examination, and annual physical fitness examination.
subsections: section_title: Indications of Noncompliance with 5-Year Medical Examination and Annual Medical Certificate Exist at All Components
paragraphs: A review of available medical files at one Army National Guard and one  Army Reserve location, data from a Navy report, test results of two units  in a Marine Corps battalion, and data from a review conducted by the Air  Force Audit Agency indicate some noncompliance with the routine  medical examination and the annual medical certificate at all components.  For example, in April 2005 we conducted a review of 39 medical files at an  Army National Guard unit that was deployed to Iraq in 2003 for 1 year. We  found that 13 members were not in compliance with the routine medical  examination at the time of our review. Further, while 36 members were in  compliance with the annual medical certificate at the time of our review,  only 3 members were in compliance with the annual medical certificate  prior to the unit being alerted of their most recent mobilization date for  deploying to Iraq. According to the commander of this unit, there are a  number of actions that need to be accomplished during weekend drills,  and with limited time and resources available, completing routine medical  requirements is low on the long list of priorities. In addition, during June  2005, we reviewed 175 medical files of an Army Reserve unit that deployed  to Afghanistan in 2003 for 10-month deployment. We found that all but 2  members were in compliance with the 5-year medical examination. While  150 members were in compliance with the annual medical certificate at  the time of our review, not a single member was in compliance with the  annual medical certificate prior to the unit receiving alert orders of their  mobilization. Furthermore, many of the soldiers that we spoke with during  our review stated that they were unfamiliar with the annual medical  certificate. In addition, a February 2005 Army Inspector General Report  noted that virtually all reserve component leaders they contacted during  their review expressed frustration with their inability to maintain the  medical deployability status of their soldiers using the annual medical  certificate process. Leaders noted the certificate only reflects what a  soldier is willing to share. Often the only medical personnel available to  review and sign the certificate is a unit medic, who can do little more than  ask if the data are correct.
In July 2005, the Navy reported that 96.8 percent of reserve members had  completed the routine 5-year medical examination and 94 percent of  reserve members had completed the annual medical certificate. These high  rates are due, in part, to the high priority placed on medical and dental  compliance throughout the Navy Reserve.
Although the Marine Corps Reserve does not currently have  componentwide automated information on medical compliance, it does  conduct a periodic site inspection called the Mobilization Operational  Readiness Deployment Test (MORDT). We reviewed the results of the  MORDT at two units of a Selected Reserve Battalion that had been  mobilized. The first unit test results we reviewed indicated that 98 percent  of the reservists had completed a routine physical examination within 5  years, and 90 percent had submitted annual health certifications. The  second unit test results also indicated that 98 percent of the reservists had  completed a routine annual physical within 5 years, and 88 percent had  submitted annual health certifications. According to Marine Corps Reserve  officials, all Marine Corps Selected Reserve units are subjected to an  unannounced test prior to mobilization to ensure the unit can deploy.
The Air Force Audit Agency (AFAA) recently concluded its review of the  Service’s Individual Deployment Process, during which it found significant  problems with the Guard’s and Reserve’s medical records. Ten Air  National Guard and Air Force Reserve installations included in a sample of  20 installations designed to be able to produce estimates for all Air Force  personnel who were eligible to be deployed during the 90-day window  between June 1, 2004, and August 31, 2004, were in compliance with  medical requirements such as, but not limited to, annual medical  assessments and dental examinations. The AFAA reviewed the medical  records and associated documentation for accuracy and completeness.  Based on AFAA’s review and analysis of 14,121 eligible Guard and Reserve  members combined, about 13 percent were found to have medical  discrepancies in their medical records. At 2 of the unit commands  included in AFAA’s review that we also visited in our review, command  officials said that they agreed with the AFAA’s findings and were taking  corrective action.
section_title: Indications of Noncompliance with Dental Examinations Exist at All Reserve Components
paragraphs: Indications of noncompliance with the dental examination requirement  were also present at all the reserve components. For example, as  previously noted, in April 2005, we conducted a review of 39 medical files  of an Army National Guard unit; of these, 33 were not in compliance with  the annual dental examination at the time of our review. Furthermore, 32  members were not in compliance with the annual dental examination prior  to alert. In June 2005, we visited an Army Reserve unit to conduct a review  of 175 medical files. Although only 13 members were not in compliance  with the annual dental examination at the time of our review, over 130  members were not in compliance with the dental examination prior to  alert.
Other evidence indicates that compliance with dental requirements has  been a particular matter of concern for the Army reserve components.  According to a February 2005 Army Inspector General Report, there are  examples of reserve component service members with multiple tooth  extractions at nearly every mobilization station. Furthermore, in cases  where members presented dental records during mobilization, often the  only entries are dated to the members’ basic training and initial exams and  procedures. We found a stark example of what happens during  mobilization when a member’s dental status is allowed to remain below  Class I or II. In one unit we visited, we interviewed a member who had 30  teeth extracted prior to deployment. According to the member, although  dental screenings were conducted annually, indicating that he was a dental  class III he took no follow-up action to correct his dental problems  because he had no dental insurance and correcting the problem was not a  priority. At the time this servicemember was being mobilized, a  Department of the Army memo dated December 6, 2002, stated that  soldiers assigned to designated units scheduled to deploy within 75 days of  mobilization and identified as being within dental class III or IV have  necessary dental treatment initiated to bring them up to dental  classification II, the deployment standard.
Although we did not review individual medical and dental records at Navy  and Marine Corps Reserve sites we visited, we did review specific reports  to assess whether these components monitored members’ dental status.  We found that the Navy Reserve compliance appears to be improving. For  example, in early July 2005, the Navy reported that 88.6 percent of selected  reservists were in a Dental Class I or II category, an increase over the 69  percent reported in the Dental Class I or II category in December 2002. We  also reviewed MORDT results for two Marine Corps units during a site  visit to a Marine Corps Reserve Battalion that had been mobilized. We  found that test results for the first unit indicated that 85 percent were  categorized as Dental Class I or II while 77 percent in the second unit were  categorized as Dental Class I or II.
Analysis provided by the AFAA from its review, mentioned earlier,  indicated that about 13 percent of the Air National Guard and Air Reserve  members who were eligible to be deployed between June 1, 2004, and  August 31, 2004, were found to have discrepancies in their dental records.  In addition to the AFAA review, in 2004 the Air Force Inspection Agency  conducted health services inspections and found discrepancies in dental  readiness classifications in 49 percent of the 37 installations reviewed.
section_title: Indications of Noncompliance with Physical Fitness Examination Requirement Exist at All Reserve Components
paragraphs: As with the other examination requirements, we also found indications of  noncompliance with the physical fitness examination requirement at all  six components.
During our review in April 2005 we also reviewed 29 physical fitness files  of the Army National Guard unit that deployed to Iraq. Of the 29 physical  fitness files we reviewed, only 18 members showed compliance with the  physical fitness examination requirement during 2004. Of these 18  members, 11 passed the physical fitness test and 7 failed. According to the  unit commander, some soldiers possess skills that are greatly needed for  unit continuity and strength and usually outweigh the ramifications of  having to separate the member due to physical fitness test failures. We  also conducted a review in June 2005 of 227 physical fitness files of the  Army Reserve unit that deployed to Afghanistan. Of the 227 physical  fitness files we reviewed, only 117 members showed evidence of  compliance with the physical fitness examination requirement during  2005. Of these 117 members, 89 passed the physical fitness test and 16  failed. In group discussions held at this time, members stated that there  were no repercussions for failing the physical fitness test. As previously  reported in our 1994 report, we also found that physical fitness scores  had been inappropriately changed and servicemembers were not  discharged even after repeated test failures, primarily because  commanders placed more emphasis on maintaining unit strength.
While visiting a Navy Reserve Activity, we obtained a single unit’s physical  fitness test results to ensure data were properly maintained in the Physical  Readiness Information Management System. However, when we asked the  Navy Personnel Command to provide a copy of the required physical  fitness report, we learned the report would be submitted to OSD late.  According to a Navy official, the Navy had identified over 2,000 duplicate  record entries and estimated that nearly 25 percent of the body fat scores  were missing from the data totals. In its report to OSD, the Navy reported  that it had not mandated separation processing for individuals who failed  the physical fitness test since May 2001.
During a visit to a Marine Corps Reserve Center, we also obtained  information that indicated individual Marine Corps reservists’ physical  fitness scores were recorded in the Marine Corps Total Force System.  Subsequent to our visit, however, we learned that the Marine Corps also  provided an unofficial “draft” physical fitness report to the OSD after the  deadline. In order to review Marine Corps physical fitness statistical data,  we requested a copy of the report on April 6, 2005. As of October 2005, the  Marine Corps had not responded to our request.
The Air Force did not meet OSD’s required due date in submitting its first  annual report on its assessment of the physical fitness, body fat, and  health promotion program for the active service, the Air National Guard,  and the Air Force Reserve. The Air Force did not submit its annual report  until May 4, 2005. Based on the data provided by the Air Force for the Air  National Guard and the Air Force Reserve, only 83 percent of the force  members were tested, with 13.2 percent of those tested falling into the  poor category. However, the Air Force’s assessment of one of its reserve  component’s statistical data may not be entirely correct. In its reported  statistical information of the numbers of members tested, those members  testing in the poor category are higher than those numbers directly  reported by the Air National Guard to the Air Force Medical Support  Agency, which consolidated the respective components’ data and in turn  submitted the overall report to the Assistant Secretary of Defense for  Force Management Policy. In addition, as discussed earlier, we were  unable to determine that the data used from the Air National Guard and  Air Force Reserve databases that generated these data are reliable.
section_title: DOD Lacks Visibility over the Health Status of Reserve Components after Being Called to Active Duty and the Extent to which Members with Preexisting Conditions Required Care during Deployment
paragraphs: DOD does not have complete visibility over the health status of reserve  component members after they are called to duty and is unable to  determine the extent of care provided to those members deployed with  preexisting medical conditions. Despite the existence of various sources of  medical information, DOD has incomplete visibility over members’ health  status when called to active duty, primarily because the reserve  components vary in their ability to systematically identify, track, and  report members’ medical deployability and the DOD-wide centralized  database cannot provide complete information—both of which hinder  DOD’s ability to accurately determine what forces remain for future  deployments. In addition, DOD is unable to determine the extent to which  reserve component members received care for preexisting medical  conditions while deployed; however, evidence suggests that reserve  component members did deploy with preexisting medical conditions that  could not be adequately addressed in theater and that some of these  conditions may have stressed in-theater medical capabilities.
subsections: section_title: Visibility over Health Status of Reserve Members after They Are Called to Active Duty Is Limited
paragraphs: Although DOD has some visibility over reserve component members after  they are called to active duty or mobilized, this visibility is limited despite  several potential sources of information. For example, the reserve  components vary in their ability to systematically identify, track, and  report information about members’ medical deployability, which limits  DOD’s visibility over the health status of members. In addition, although  medical information is captured on predeployment forms for all reserve  component members and entered into a DOD-wide centralized database  during mobilization, some data are still missing and information regarding  the reasons why members were found nondeployable is not captured in a  way that can be easily searched through the database. Moreover, medical  referral data captured on the predeployment forms provide some insight  into the care that members may have required during mobilization, but this  care is not always related to why a member was determined to be  medically nondeployable. Some data on the medical reasons why Army  Guard and Reserve members were not deployed after being activated can  be obtained from an analysis of the Army’s medical holdover database, but  this information is insufficient to provide DOD with visibility over  members’ health status since it is only gathered on the numbers of Army  reserve components held prior to deployment and this population is  diminishing due to positive changes in Army’s medical holdover policy.  DOD’s limited visibility over reserve component members’ health status  when they are called to active duty could affect planning for future  deployments because the pool of available Guard and Reserve component  members from which to fill requirements for certain skills and grades is  dwindling, and members’ health status is deteriorating following  deployments.
subsections: section_title: Reserve Components Vary in Ability to Identify, Track, and Report Medical Nondeployable Members
paragraphs: The reserve components vary in their ability to systematically identify,  track, and report members’ medical deployability, and only three reserve  components—the Navy Reserve, the Air Force Reserve, and Air National  Guard—can currently identify and track members with both temporary  and permanent conditions that limit medical deployability. This limited  visibility over reserve component members’ medical deployability status  hinders DOD’s ability to identify the pool of available Guard and Reserve  members who are available for deployment.
The Navy Reserve uses the Medical Readiness Reporting System (MRRS)  to track and report the status of reservists classified as Temporarily Not  Physically Qualified for duty because of an illness, injury, or other medical  condition that should be resolved within 6 months. This system is also  used to track and report the status of reservists, classified as Not  Physically Qualified for duty, with more serious medical conditions such  as cancer or heart disease that will not be resolved in 6 months and may  lead to a medical review or board retention decision. As the Marine Corps  Reserve continues to fully implement the Navy’s Medical Readiness  Reporting System, it too will have these same capabilities. Both the Air  National Guard and the Air Force Reserve’s medical tracking systems— PIMR and RCPHA, respectively—can identify and track members with  specific medical conditions that limit deployment; however, neither  system can distinguish between temporary and permanent limitations. In  addition, the Air Force has a system called Military Personnel Data System  that captures information on all medical profiles and can report specific  queries on specific categories such as temporary and permanent  conditions. Although the Army tracks active, guard, and reserve members  with medical profiles that limit deployment through their medical tracking  system, MEDPROS, the active Army and Army Reserve do not presently  track members with temporary medical conditions that render them  nondeployable. However, the Army National Guard is in the process of  implementing a system, called the Medical Non-Deployable Tracking  Module (MND-TM), that will track its members who have a temporary or  permanent medical condition that renders them nondeployable. Army  National Guard officials expect all states to use this system for its  members by July 2007. Until all six reserve components are able to  systematically identify and track members’ medical deployability status,  DOD will not have the most accurate information to centrally manage  estimating the remaining available pool of guard and reserve members for  future deployments.
section_title: Centralized DOD-wide Database Provides Some Visibility over Health Status During Mobilization, but Data Could Be Further Improved
paragraphs: DOD has some visibility over reserve component members’ medical status  during mobilization through the centralized DOD-wide database operated  by the Army Medical Surveillance Activity (AMSA). All active and reserve  component members are required to complete a medical predeployment  form to document the member’s medical deployability status, which is  then forwarded to AMSA for entry into the database. Thus, information  can be obtained from the centralized database on reserve and active  component members who were determined nondeployable during  mobilization due to medical reasons. The member also completes a health  assessment form after deployment. However, we have noted in previous  reports that the centralized database has missing and incomplete forms. In  our last report issued in September 2004, we found that for the required  forms from reserve component members (1) not all of the forms had  reached AMSA, (2) only some of the forms that had reached AMSA had  been entered into the database, and (3) not all of the forms contained  complete information, thus limiting analysis.
We also noted that while the components were not in complete  compliance with the requirement to submit pre- and postdeployment  assessments, the number of assessments had grown significantly. During  this review, we found that DOD has continued to make progress toward  collecting the pre- and postdeployment forms. According to AMSA  officials, the database contained about 140,000 assessments at the end of  1999, grew to about 1 million assessments by May 2003, almost doubled at  1,960,125 by June 2004, and was at 2,241,177 by June 2005.
Further, DOD has established a centralized deployment health quality  assurance program to improve data collection and accuracy. Each  service has also developed a deployment health quality assurance  program. The department’s first annual report, documenting, among other  things, issues relating to predeployment health assessments, was issued in  May 2005. The DOD quality assurance program includes (1) periodic site  visits jointly conducted with staff from the Office of the Assistant  Secretary for Health Affairs and staff from the military services to assess  compliance with the deployment health requirements, (2) periodic reports  from the services on their quality assurance programs, and (3) periodic  reports from AMSA on health assessment data maintained in the  centralized database. The report noted that centralized management of  quality assurance had improved accountability of the preassessment forms  on the part of the services.
For this review, we obtained predeployment information from AMSA  officials based on over 1 million active and reserve component  predeployment health assessment forms collected between November  2001 and June 2005. More than 5 percent of the reserve component and  more than 6 percent of the active component predeployment health  assessment forms did not record the servicemember’s deployability status.  Of the approximately 94 percent of forms that were complete, nearly the  same percent of reserve component and active component members were  found medically deployable, 94 percent of the reserve component  members compared to 96 percent of the active component members.  Unfortunately, the forms do not always capture information regarding the  reasons why members were found medically nondeployable or do not  capture that information in a systematic way. For example, although the  form has an entry for a narrative explanation to explain why a member is  medically nondeployable, an AMSA official informed us that these  explanations are often incomplete or not decipherable, and can not be  easily categorized. Furthermore, although the forms do provide space for  the member’s deployment destination, this information is not always filled  in because, according to AMSA officials, deployment destination is often  not known by the member or is classified. Therefore, the data presented  here are for all worldwide deployments, including the United States, and  could change after the initial deployment, thus preventing an analysis by  operation.
As seen in table 1, the total nondeployable rate for all six reserve  components was more than 5 percent, while table 2 shows the total  nondeployable rate for the active component was almost 4 percent. While  the Army Reserve had the highest percentage of nondeployable  servicemembers among the reserve components, at about 9 percent, the  active Army had the highest percentage of nondeployable servicemembers  among the active components, at almost 6 percent. According to medical  officials, some of these nondeployable personnel, such as those who had  suffered multiple heart attacks, should have been discharged prior to the  time that they received their mobilization orders. Others had temporary  conditions, such as broken bones and pregnancies, that did not warrant  medical discharges but made the servicemember nondeployable at the  time of the assessment.
The predeployment health assessment forms capture information on  specific medical referrals given to members by the reviewing health care  official during mobilization, which is useful in gaining some insight into  the care that members may have required during mobilization. These data  are not as helpful in determining why a member was not medically  deployable since they are not always related to why a member was  determined to be nondeployable. According to a senior OSD official,  although any indicated referral may be related to a disposition of  nondeployable, this is not always the case. Three common scenarios  illustrate this relationship: (1) a member is found to be clearly  nondeployable from a medical standpoint, and no referral is made; (2) a  member is referred for further evaluation for a condition for which  deployability is questionable, in which case there is a direct relation  between the referral and the determination of deployable or  nondeployable; or (3) a member is found to be deployable, but has a minor  medical issue for which the health provider provides a referral for  treatment. According to a senior OSD official, the last scenario is a fairly  uncommon reason for a referral. Examples might include a referral for a  routine preventive test, such as a Pap test in a gynecological clinic. The  Pap test is a desired preventive medical test, but depending on the date  and result of the last Pap exam and the individual’s personal history and  risk factors, it is not always necessary to perform one prior to deployment.
More than 50,000 referrals were made on the predeployment health  assessments from November 2001 through June 2005 for both the active  and reserve components. As shown in table 3, of the 21,000 forms with  referrals for reserve component members, the referral rate averaged more  than 5 percent. As shown in table 4, of the 24,633 forms with referrals for  their active duty counterparts, the referral rate was about 4 percent.
Within the reserve components, the Army Reserve had the highest referral  rate at nearly 8 percent, while the Air National Guard and Air Force  Reserve had the lowest rates, both at less than 1 percent.
There are 18 categories of referrals that can be checked on the  predeployment form, of which 1 is “other” and does not provide any  further detail. As seen in figure 1, the top 3 medical referrals for the  reserve components were “other,” “dental,” and “eye,” whereas the top 3  referrals for active components were “other,” “dental,” and “orthopedics.”  The rate of medical referrals for the reserve components was almost 40  percent and for the active components was almost 50 percent.
Although the AMSA referral data do provide some insight into the medical  care required during mobilization, the referral data are not detailed enough  to determine the type of medical referral or determine the reason for  nondeployment.
section_title: Army Medical Holdover Database Provides Data on Activated Members Who Were Not Deployed Due to Medical Problems
paragraphs: The Army’s medical holdover database, a module within the Medical  Operational Data System (MODS), does provide DOD with a snapshot of  data about the number of Army National Guard and Reserve members who  were not deployed after being called to active duty because of medical  problems and the medical reasons why they were not deployed after being  activated. Although all of the services may keep reserve component  members on active duty if they incur an injury in the line of duty following  deployment, only the Army has held reserve component members in need  of medical care at military treatment facilities prior to deployment. These  servicemembers are referred to as the medical holdover population.  Because of the large numbers of activated Army National Guard and Army  Reserve members placed in medical holdover by the Army in the early part  of Operation Iraqi Freedom, the Army Office of the Surgeon General  created a module in an existing database to track them. We examined the  Army medical holdover data to obtain information about the possible  reasons why servicemembers were found to be medically nondeployable.  However, the data cannot provide complete visibility over members’  health status because the population receiving medical care from the Army  prior to deployment is diminishing due to changes in Army’s medical  holdover policy. Further, until January 2005, MODS was not used  consistently by all case managers responsible for servicemembers in  medical holdover.
Between December 2002 and October 2003, 4,850 activated Army reserve  component members were found medically nondeployable and kept on  active duty until their medical problems had been resolved and they were  returned to full duty or until they had been referred to a medical board and  discharged from the Army. In October 2003, the Army changed its policy to  allow the demobilization of personnel who were found to be  nondeployable within the first 25 days of activation. In accordance with  this policy, reserve component servicemembers identified in the first 25  days as having a medical condition that renders the individual  nondeployable may be released from active duty immediately. As a result  of this policy change, the Army was able to demobilize reserve component  members who were found to be nondeployable within the first 25 days of  their mobilization. The change also reduced the inflow of reserve  component members on active duty with medical problems who were  identified during the predeployment health assessment process. As of  August 11, 2005, only 860 reserve component members were in a  medical holdover status as a result of a medical condition found prior to  deployment.
As shown in figure 2, the most common medical condition that has  prevented a reserve component member from deployment is orthopedic  in nature—accounting for 56 percent of the 860 Army National Guard and  Army Reserve members who were found medically nondeployable and  placed in a medical holdover status—followed by internal medicine at 16  percent, and neurological problems at 8 percent.
Despite the more specific information about medical status that can be  obtained by reviewing these medical holdover data, the data are fairly new  and limited to those held at medical treatment centers.
section_title: Lack of Visibility over Reserve Component Members’ Health Status Could Affect Planning for Future Deployments
paragraphs: Although senior military officials at various levels of command told us that  the health status of reserve component members did not affect  deployment schedules, the extent to which unit commanders have had to  find replacement members to fill in for members who were medically  unqualified upon alert, the reasons why, and how, or if, this impacted  planning of operations in Iraq and Afghanistan are unknown. However,  DOD’s lack of visibility over reserve component members’ health status  when they are called to active duty could affect planning for future  deployments as the demand for troops for the Global War on Terrorism  continues.
The Army has had to transfer reserve component personnel from  nonmobilized units to mobilized units to meet mission requirements. For  example, the Army Inspector General reported in February 2005 that with  increasing frequency, Army units identified for alert and mobilization had  previously provided members to other units. The report noted that  frequently more than half of a deploying unit’s personnel had been  transferred into the unit to meet personnel requirements. This “ripple  effect” is occurring across the Army reserve force, and each subsequent  mobilization requires more and more personnel transfers to meet  personnel requirements. The need for these personnel transfers is largely  due to an outdated Cold War strategy that planned to use the reserve  forces as a later deploying force and therefore did not give them full  resources. As more units are used for this “cross-leveling”, it becomes  even more important that the Army have good visibility over the health  status of the remaining reserve component members.
In addition, as shown in table 5, the health status has declined for active  and reserve components after returning from deployment as shown by  data from the pre- and postdeployment health assessments. The Army  National Guard and Army Reserve had the highest percentage of  servicemembers indicating their health as fair to poor on the  postdeployment health assessment.
As the pace of operations for the reserve forces continues to be high and  the health status of returning members is diminished, it becomes even  more important that DOD has good visibility over the availability of  remaining units. Improved visibility and tracking of the health status and  medical deployability of these members is a key component in the  calculation of the members available for planning future deployments.
section_title: Extent to which Members with Preexisting Medical Conditions Required Treatment during Deployment Cannot Be Determined
paragraphs: DOD cannot determine the extent to which reserve component members  received care for preexisting medical conditions while deployed in  theater because DOD has not determined what preexisting medical  conditions may be allowed into specific theaters of operations. The  purpose of examining members and properly screening them at the  mobilization stations is to help ensure that members are medically and  physically fit to deploy and do not have any condition that would  adversely affect the mission. As noted in DOD guidance, fitness  specifically includes the ability to accomplish the task and duties unique to  a particular operation, and the ability to tolerate the environmental and  operational conditions of the deployed location. Specific medical  deployment criteria for proper screening are essential for determining  preexisting medical conditions that can not be adequately addressed in  theater and could stress in theater medical capabilities. While evidence  suggests that members did deploy with preexisting conditions, the total  impact of this is unknown.
subsections: section_title: While Specific Deployment Criteria for Operations Enduring Freedom and Iraqi Freedom Continue to Evolve, Tracking of Known Preexisting Conditions Has Not Begun
paragraphs: Developing and updating medical criteria for a specific theater of  operations are the responsibilities of the combatant commands—for  Operation Enduring Freedom and Operation Iraqi Freedom this is U.S.  Central Command (CENTCOM). The CENTCOM medical deployment  criteria have been evolving over the course of these operations.  CENTCOM has updated this guidance six times throughout these  operations to include more specific guidance to the theater of operations;  the last update was issued in January 2005. During the initial mobilizations  for these operations, the services were dependent on CENTCOM general  deployment criteria issued in May 2001, which did not identify medical  conditions that would render a member medically unfit for these  operations. In the absence of specific guidance early on during the  operations, the services relied upon their own medical deployment  criteria. For the Army, specific criteria did not exist until February 2005.
The original CENTCOM deployment criteria made a general statement that  all personnel must be assessed and determined to be medically and  psychologically fit for worldwide deployment to a combat theater and that  the in-theater health infrastructure provides only limited medical care. Not  until May 2004 did CENTCOM update its deployment criteria to include  more specific guidance. This updated guidance stated that  servicemembers who have existing medical conditions may deploy if all of  the following conditions were met: (1) an unexpected worsening of the  condition is not likely to have a medically grave outcome; (2) the condition  is stable; and (3) any required ongoing health care or medications must be  immediately available in theater in the military health system, and have no  special handling, storage, or other requirements, such as electrical power.  The criteria provided a list of conditions that may preclude medical  clearance for DOD civilians and contractors (including current heart  failure, history of heat stroke, and uncontrolled hypertension); however,  according to CENTCOM officials, this list of conditions did not apply to  servicemembers because they were already covered by service-specific  guidelines. The most recent CENTCOM deployment criteria applicable to  all servicemembers and DOD civilians and contractors were issued in  January 2005, and update theater-specific immunization requirements and  provide more detailed guidance on contact lens wear, among other things.  As these policies are developed, the combatant command is to provide  them to the services, which are then responsible for determining how they  implement the screening requirements in terms of screening their  deploying forces, including activated reservists.
Because DOD has not determined what preexisting conditions may be  allowed into a specific theater of operations, it has not known what  preexisting conditions to track. As noted, the medical deployment criteria  for the current theater of operations have been evolving, but specific  medical deployment criteria have not been developed for other potential  theaters of operation. However, some preexisting medical conditions may  be common to all theaters of operation. DOD has not determined this.  Further, although DOD has a number of systems for tracking medical  conditions in theater, the current databases have not been modified to  capture data on known preexisting conditions for this specific operation.  For example, the Joint Medical Workstation (JMeWS) provides medical  treatment status and medical surveillance information, as well as tracks  and reports patient location within a theater of operations and during  evacuation from frontline medical units to stateside medical treatment  facilities. The U.S. Transportation Command (TRANSCOM) utilizes the  TRANSCOM Regulating Command and Control Evacuation System  (TRAC2ES) to document patient movements, such as medical evacuations.
The Joint Patient Tracking Application (JPTA) was initially designed for  use within Landstuhl Regional Medical Center in Germany as a way to  manage Operations Enduring Freedom and Iraqi Freedom patients. In  2004, the services were directed by the Assistant Secretary of Defense for  Health Affairs to implement JPTA at military treatment facilities in theater  and the continental United States to improve patient tracking and  management. The Disease Nonbattle Injury (DNBI) rates for the services  in Operations Enduring Freedom and Iraqi Freedom are tracked in the  DNBI database by the Air Force Institute for Operational Health. We did  not evaluate these systems since they do not distinguish care provided for  preexisting medical conditions.
section_title: Evidence Suggests that Reserve Component Members Have Been Deployed into Theater with Preexisting Medical Conditions
paragraphs: Although DOD does not systematically develop or report information  about the extent of care that was provided in theater to reserve  component members for preexisting medical conditions, senior military  medical officials who served in theater have provided examples of reserve  component members who were deployed with preexisting medical  conditions that could not be adequately addressed in theater. Some  officials told us that such treatments strained in theater medical  capabilities and infrastructure.
According to a senior military official in the surgeon’s office of the  commander in chief of the U.S. Central Command (CENTCOM), there  were many instances of individuals, from all services, who deployed into  the Iraq and Afghanistan theater of operations with conditions for which  they should have been considered nondeployable. Also, medical officials  from both the Army and Navy cited examples of conditions seen in theater  that should have rendered members nondeployable. Among the examples  cited were members with a history of heart attack, severe asthmatics (the  desert conditions were not suitable for these members), severe  hypertension, a woman 4 months into chemotherapy for breast cancer,  and a man who had received a kidney transplant 2 weeks prior to  deploying. Other examples included cases involving members deployed  with sleep apnea requiring machines that are run by electricity, even  though electricity was either unavailable or unpredictable. Another  soldier, we were told, who arrived in theater was diabetic and required an  insulin pump for treatment. We were also told of a number of psychiatric  patients who were suffering from conditions such as bipolar disorder who  should not have been in the desert because the medications that they were  taking caused them to sweat profusely. One Air Force Reserve medical  official who served in theater preparing members to be medically  evacuated estimated that of the approximate 2,000 reservists she helped to  evacuate, 10 percent being evacuated were due to preexisting conditions  such as diabetes and heart problems, with the most common condition  being diabetes. The commander of an Army Guard unit deployed to Iraq  told us about a member who had deployed with a preexisting knee  problem for which he had to be returned to the United States to correct.  The issue was eventually resolved and the member was allowed to  redeploy with his unit.
According to a September 2004 Air National Guard Surgeon General  memorandum, unacceptable dental health should preclude a member  from deploying under any circumstances because dental resources do not  exist in theater. However, the Air National Guard’s Surgeon General has  noted that dental emergencies are historically and currently the most  common preventable reason for loss of manpower in the wartime theater.  In addition, the Air Force’s Air Surgeon Chief of Medical Services  Directorate commented on January 17, 2003, in response to a case  involving an Air National Guard member who had been sent into theater  with an obvious major preexisting dental condition, that it is unreasonable  to expect deployed doctors and dentists to perform remedial procedures  and provide care that should have been accomplished at home because it  takes too much time away from treating injured and ill in theater, and it  results in lost man hours for the gaining unit that it needs to accomplish its  war-fighting requirements. In our small group discussions with Army  National Guard, one servicemember said that he was told that he would  receive dental care in theater, although this care was never provided. At  one Air National Guard unit command we visited, officials informed us of  a member who was mobilized and subsequently deployed with preexisting  dental problems in late 2003, because (1) the dental condition was not  disclosed by the member and (2) the unit command did not have a current  dental exam in his medical records to prove otherwise. The member  would not have been deployed had his true dental condition been initially  identified, but he received substantial dental work while deployed.  According to a unit command official, the member was subsequently  returned to his unit command because his dental costs and related work  downtime were excessive.
section_title: Other Reasons Members May Have Arrived in Theater with Preexisting Conditions
paragraphs: In addition to a lack of specific guidance from CENTCOM to the services  early in the operations, military medical officials told us other reasons why  members may have arrived in theater with preexisting medical conditions.  First, military officials stated that in some cases members did not disclose  their preexisting medical conditions because they wanted to serve their  country. A Navy official, for example, stated that a Navy officer with  hypertension did not disclose his medical condition in order to deploy to  Iraq to support Operation Iraqi Freedom. Because the officer’s medical  condition worsened in Iraq, the Navy had to return him to his home unit  and find a replacement to fill his position. We were also told of members  who arrived in theater with preexisting conditions with the expectation  that they would be taken care of while they were there. For example, a  senior medical official stated that one servicemember arrived in theater  with one kidney and in need of dialysis, which was not available in theater.  Early in operations several servicemembers with hernias were deployed  with the expectation that the surgery would be conducted in theater.
It is important to have up-to-date medical criteria specific to a theater of  operations to alert members to changing condition in theater or new  information on vaccinations, for example. Developing and updating  medical criteria for a specific theater of operations is the responsibility of  the commander in chief of the combatant command—in this case,  CENTCOM. As these polices are completed and updated, the combatant  command is to provide them to the services, who are then responsible for  determining how they implement the requirements in terms of screening  their deploying forces including activated reservists.
section_title: Conclusions
paragraphs: The findings we present in this report are not new. In the aftermath of the  first Persian Gulf War, a number of DOD and GAO studies were issued that  identified problems with guard and reserve personnel being medically and  physically fit for duty. DOD agreed with many of the studies’ findings and  recommendations but never developed a plan with goals, time frames, and  measurable results to improve visibility over reserve component members’  health status. At times, Congress has stepped in and directed DOD to make  a number of improvements, especially for quality assurance and tracking  of health assessment data collected before and after a member’s  deployment. Congress recently directed OSD to develop and implement a  comprehensive plan to improve management of the health status of the  reserve component. The importance of such a plan has become even more  important in the current environment, where the pool of guard and reserve  members with the right skills from which to fill requirements for DOD’s  overseas and domestic commitments is dwindling.
Further, many of DOD’s personnel policies, including its medical policies,  are outdated, as they are based on Cold War strategy that allowed the  reserve force more time to mobilize before deployment. Now the reserve  force deploys with the active force and is expected to be medically and  physically fit when called to duty. The lack of oversight of reserve  members’ health status, however, does not appear to be unique to the  reserve component. Oversight, as seen in the area of enforcing DOD’s  reporting requirement on the status of physical fitness for both the active  and reserve components, has not taken place. No repercussions exist if a  service does not provide this report on time, nor are there any deadlines  for the annual report to be submitted to OSD.
OUSD/P&R has the authority to set medical and physical fitness policy and  processes to oversee this area; however, OUSD/P&R has not taken action  to exercise its authority to address these long-standing problems.
section_title: Recommendations for Executive Action
paragraphs: As DOD proceeds to develop a comprehensive plan for improving  management over the health status of the reserve components in response  to the Ronald W. Reagan National Defense Authorization Act for Fiscal  Year 2005, we recommend six actions.
To have visibility over reserve components’ compliance with routine  medical and physical fitness examinations, we recommend that the  Secretary of Defense    direct the Under Secretary for Personnel and Readiness, in concert with  the Assistant Secretary for Health Affairs and the Principal Deputy to the  Under Secretary, to establish a management control framework and  execute a plan for issuing guidance, establishing quality assurance for data  reliability, and tracking compliance with routine medical and physical  fitness examinations; and    direct the Under Secretary for Personnel and Readiness, in concert with  the Principle Deputy who oversees the Office of Morale, Welfare, and  Recreation, to take steps to enforce the service reporting requirement on  the status of members’ physical fitness in conjunction with the actions  taken in the first recommendation.
To improve DOD’s visibility over reserve components’ health status after  they are called to duty, we recommend that the Secretary of Defense    direct the Under Secretary of Defense for Personnel and Readiness, in  concert with the Assistant Secretary of Health Affairs, to also oversee the  development of the reserve components’ tracking systems to identify and  track members’ temporary and permanent medical conditions that limit  deployability; and    direct the Under Secretary of Defense for Personnel and Readiness, in  concert with the Assistant Secretary of Health Affairs, to modify the  medical predeployment forms to better capture reasons for  nondeployment and medical referrals.
To help prevent the deployment of reserve component members with  preexisting medical conditions that could adversely affect the mission and  strain resources in theater, and to provide visibility over those members  deployed with preexisting conditions for which treatment can be provided  in theater, we recommend that the Secretary of Defense:    direct the Chairman of the Joint Chief of Staff to determine what  preexisting medical conditions should not be allowed into specific  theaters of operations, especially during the initial stages of the operation,  and to take steps to ensure that each service component consistently  utilizes these as criteria for determining the medical deployability of its  reserve component members during mobilization; and    direct the Chairman of the Joint Chief of Staff, in concert with the service  secretaries, to explore using existing tracking systems to track those who  have treatable preexisting medical conditions in theater.
section_title: Agency Comments and Our Evaluation
paragraphs: In written comments on a draft of this report, DOD did not concur with  our first and fourth recommendations, partially concurred with our fifth  recommendation, and concurred with our second, third, and sixth  recommendations. DOD did not concur with our recommendation that it  establish a management control framework and execute a plan for issuing  guidance, establishing quality assurance for data reliability, and tracking  compliance with routine medical examinations. DOD did not state that it  disagreed with our findings; however, DOD stated that it had initiatives  underway that addressed our recommendation. DOD further noted that  because policies, programs, and instructions are already in place or in  process, it did not see the need for any additional action. We disagree with  DOD’s conclusion because, based on our review, we do not believe that  DOD’s initiatives are far enough along to dismiss further action, and we  continue to believe that our recommendation has merit. We agree that the  initiatives DOD cited in its written comments are positive steps toward  correcting the identified problems, but management and planning remain a  concern. We have not seen enough evidence to agree that DOD has put in  place a management control framework that will enforce holding all  responsible levels accountable, ensuring that all routine medical  requirements are being met, and that complete and reliable data are being  entered into the appropriate tracking systems. As noted in our report, the  problems with determining the health status of the reserve force were  revealed during Operations Desert Shield and Desert Storm, and in the  decade that has passed since then DOD has made little progress to correct  the identified problems. As a result, in 2004, Congress directed DOD to  establish a Joint Medical Readiness Oversight Committee to oversee the  development and implementation of a comprehensive medical readiness  plan. As also noted in our report, the committee held its first meeting in  February 2005, and a plan to improve medical readiness was being  developed during this review. We do not believe that a committee can be  held accountable for ensuring that such actions take place. Ultimately, the  Under Secretary of Defense for Personnel and Readiness, in concert with  the Assistant Secretary for Health Affairs, are accountable for enforcing  the requirements for routine medical examinations.
Moreover, DOD stated that it has established a new quality assurance  program that monitors electronic data with validation through medical  record reviews of a wide range of force health protection measures. We  did not find this to be true during our review. With the exception of the  Navy Reserve, the reserve components do not monitor electronic data of  routine medical examinations with validation through medical record  reviews. Further, we found the data in the reserve components’ tracking  systems to be unreliable for purposes of determining compliance with  routine medical examinations. As noted in our report, compliance with  these routine medical examinations is the first step toward determining  who is medically fit or ready for duty. DOD stated that its compliance- monitoring Individual Medical Readiness program regularly reports the  overall medical readiness status for each servicemember. However, we  found that the Individual Medical Readiness program’s outcomes are  derived from data in the reserve components’ tracking systems, which we  have found to be unreliable, with the exception of the Navy Reserve, for  the purposes of determining compliance with routine medical  examinations. DOD stated that its Individual Medical Readiness program’s  data are being incorporated into overall unit readiness status reports,  providing visibility of reserve component medical readiness throughout  the line command structure. We believe that until top management at DOD  ensures that complete and reliable data on routine medical examinations  are being entered into its tracking systems, DOD and Congress will  continue to have a false picture of medical readiness for the reserve  components. We believe that our first recommendation still has merit.
DOD concurred with our recommendation that DOD take steps to enforce  the services’ reporting requirement on the status of their members’  physical fitness. DOD stated that DOD instruction 1308.3, dated November  5, 2002, among other things, requires the active and reserve components to  provide an annual report to the Principal Deputy of the OUSD/P&R not  later than March 31. DOD stated that the Air Force, the Navy, and the  Marine Corps have submitted their reports. DOD noted that exceptions to  the reporting requirement for the Air Force and the Army had been  approved. However, during our review we were told that none of the  reports had been submitted to the Principal Deputy as required. We raised  concerns in this report about the data reliability of the tracking systems  for physical fitness. We found that the reserve components are unable to  report complete and reliable data on compliance with routine physical  fitness examinations on a componentwide basis due to incomplete and  unreliable data. Just as we found with routine medical examinations, we  also found that DOD lacked quality assurance of the data on compliance  with physical fitness examinations in its tracking systems. We do not know  what data reliability issues DOD will cite in its annual reports on physical  fitness. We note that the responsible office for physical fitness oversight,  the Office of Morale, Welfare, and Recreation, does not participate in the  Joint Medical Readiness Oversight Committee that is directed to oversee  improvements in medical readiness, nor are we aware of any DOD plans to  include improvements in the oversight of physical fitness in its  comprehensive medical readiness plan. Therefore, we have expanded our  first recommendation to include routine physical fitness examinations in  the actions to be addressed.
DOD concurred with our recommendation that DOD oversee the  development of the reserve components’ tracking systems to identify and  track members’ temporary and permanent medical conditions that limit  deployability. DOD stated that it is already actively adapting existing  systems, and in some cases creating new ones, that can be used to track  the medical status of active and reserve members, to include those known  conditions that could limit an individual’s deployability. DOD noted that it  continues to pursue better integration between medical and personnel  data systems to improve visibility regarding deployment-limiting medical  conditions, whether temporary or permanent, but the overall effectiveness  will continue to be limited by lack of access to civilian medical records of  reserve component members.
DOD did not concur with our recommendation that DOD modify the  medical predeployment form to better capture reasons for nondeployment  and medical referrals. DOD stated that the best sources of accurate  information about what medical reasons kept service members from  deploying are the permanent medical records. This may be the case, but  we continue to believe our recommendation has merit because DOD has  no way to systematically analyze the information to determine why  servicemembers are medically nondeployable. Because the predeployment  form is used to document whether a servicemember is deployable, this  existing form could be modified to better capture the reasons for  determining why a servicemember is determined nondeployable. Although  the form has an entry for a narrative explanation to state why a member is  medically nondeployable, AMSA officials informed us that these  explanations are often not decipherable, incomplete, and can not be easily  categorized. DOD also stated that the existing predeployment form already  includes a list of the most common referral categories to simplify the  documentation process for the health care provider. In addition, DOD also  noted that data from the forms are captured electronically and are readily  available to monitor for trends in referral patterns, among other things. We  do not believe that any meaningful analysis for referrals can be determined  from these forms because we found that the top medical referral category  for the reserve and active components was “other”. This heavy use of the  category “other” does not provide any insight as to what medical care a  member is receiving after being called to duty. Given that the rate of  medical referrals for the reserve components was almost 40 percent and  for the active components was almost 50 percent, we continue to believe  that DOD should modify the predeployment form to better capture reasons  for nondeployment and medical referrals.
DOD partially concurred with our recommendation that DOD determine  what preexisting medical conditions should be allowed into a specific  theater of operations, especially during the initial stages of operations, and  take steps to consistently utilize these criteria for determining medical  deployability. DOD stated that certain conditions clearly should render a  member nondeployable, and the services have made strides in defining  these conditions and incorporating them into their applicable policies and  procedures. But DOD also noted that due to the ever-changing nature of a  theater of operations and the inexact nature of medicine, a list of  nondeployable preexisting conditions will never be fully comprehensive or  fully enforceable. We agree that a list of nondeployable preexisting  medical conditions can never be fully comprehensive; however, we still  believe DOD could establish a list of what preexisting medical conditions  should be allowed into specific theaters of operations, especially during  the initial stages of operations, so that in future deployments DOD would  not experience situations such as those that occurred with members being  deployed into Iraq who clearly had preexisting conditions that should have  prevented their deployment.
DOD concurred with our recommendation that DOD explore using  existing tracking systems to track those who have treatable preexisting  medical conditions in theater. DOD noted that refinements to medical  tracking system are ongoing. We wish to note that before DOD’s tracking  systems can be used to track those who have treatable preexisting medical  conditions in theater, DOD must determine what preexisting medical  conditions should be allowed into a specific theater of operations as called  for in our fifth recommendation.
DOD noted in its overall comments that the reserve and active forces use  many of the same reporting tools within each service and face the same  basic challenges in ensuring data quality. DOD stated that where tracking  systems are shared, the reserve components depend on the active  components to develop and fund those systems, and that priority for  deployment of large systems has historically been given to the active  component. DOD also pointed out that our report indicates that the health  status of members deteriorates with multiple deployments and that the  data we used are self-reported and should be taken with great caution and  in the proper context. We used the self-reported data from  postdeployment health assessments to help demonstrate the importance  of good visibility over the reserve forces. We noted that the demand for  reserve personnel, especially within the Army components, continues, and  the pool of reserve members used to fill requirements is dwindling.  Further, the health status of returning reserve and guard members is not  as good as it was before deployment as our analysis of the pre- and  postdeployment health assessments showed. Therefore, it becomes even  more important that DOD have good visibility over the health status of  remaining reserve force to help determine what is left for future  deployments.
DOD’s comments are reprinted in their entirety in appendix II.
We are sending copies of this report to the Secretary of Defense; the  Secretaries of the Army, the Navy, and the Air Force; the Commandant of  the Marine Corps; the Chairman of the Joint Chiefs of Staff; and the  Director, Office of Management and Budget. We will also make copies  available to others upon request. In addition, the report will be available at  no charge on the GAO Web site at http://www.gao.gov.
If you or your staff has any questions concerning this report, please  contact me at (202) 512-5559 or stewartd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. GAO staff who made major contributions to this  report are listed in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To assess the Department of Defense’s (DOD) ability to determine the  reserve components’ compliance with routine medical and physical fitness  examinations, we reviewed federal statutes and Office of the Secretary of  Defense (OSD) applicable directives and instructions to identify and  understand the roles and responsibilities of the offices within DOD for  management of the health status of the reserve components. We discussed  these statutes and guidance with senior officials in the Office of the Under  Secretary of Defense for Personnel and Readiness. We reviewed and  discussed service policies and regulations for medical and physical fitness  with military officials within the service surgeons’ general offices and  other service headquarters’ officials responsible for physical fitness in the  service personnel and operations functions. We also reviewed and  discussed reserve component policies and guidance for medical and  physical fitness examinations with officials within the reserve component  surgeons’ general offices and other reserve component officials  responsible for physical fitness in the respective reserve component  personnel and operations functions. We interviewed cognizant officials  involved with policy development, administration, tracking, and reporting  on compliance with medical and physical fitness examinations from the  following offices or commands:  Office of the Secretary of Defense    Assistant Secretary of Defense for Health Affairs, Deployment Health    Assistant Secretary of Defense for Reserve Affairs; and    Principal Deputy Under Secretary of Defense for Personnel and Readiness,  the Office of Morale, Welfare, and Recreation.
Assistant Secretary of the Army, Manpower and Reserve Affairs;    U.S. Army Office of the Surgeon General and Commanding General, Army    U.S. Army Reserve Command, Fort McPherson, Georgia;    National Guard Bureau;    Army National Guard;    First U.S. Army, Fort Gillem, Georgia;    U.S. Army Forces Command, Fort McPherson, Georgia;    Army Fitness School, Ft. Benning, Georgia;    Fifth U.S. Army, Fort Sam Houston, Texas;    U.S. Army Medical Command, Fort Sam Houston, Texas;    U.S. Army Dental Command, Fort Sam Houston, Texas;    Army Audit Agency; and    MEDPROS Program Office.
Assistant Secretary of the Navy, Manpower and Reserve Affairs;    Office of the Chief of Navy Operations;    Office of the Chief of Navy Reserve;    Bureau of Medicine and Surgery;    Commander Navy Reserve Forces Command, New Orleans, Louisiana; and    Navy Personnel Command, Millington, Tennessee.
U.S. Marine Corps Health Services, Headquarters;    U.S. Marine Corps Manpower and Reserve Affairs, Headquarters,  Quantico, Virginia; and    Marine Forces Reserve, Headquarters, New Orleans, Louisiana.
Department of the Air Force, Headquarters;    Assistant Secretary of the Air Force for Manpower and Reserve Affairs;    Office of Air Force Reserve, Headquarters;    Air Force Reserve Command, Robins Air Force Base, Georgia;    National Guard Bureau;    Air National Guard, Headquarters;    Air National Guard Readiness Center; and    Air Reserve Personnel Center, Denver, Colorado.
We also conducted medical and physical fitness file reviews with an Army  National Guard unit from the Mid-Atlantic region and an Army Reserve  unit from the Mid-west region. We chose units that had deployed for  Operations Enduring Freedom or Iraqi Freedom. During these visits we  collected and analyzed information from available medical and personnel  files to assess the reserve component members’ compliance with routine  medical and physical fitness examinations. We also documented  difficulties the units had in ensuring that all members complied with  medical and physical fitness examinations. Finally, during the site visits,  we conducted group discussions with unit members regarding their  experience with routine examination requirements.
To gain a better understanding of how the components collect data about  their members’ compliance with routine medical and dental examinations  and physical fitness assessments, we assessed the reliability of data  produced by several services’ databases. Assessing the reliability of the  services’ data included consideration of issues such as the completeness  and currency of the data from the respective database system’s program  managers, administrators, and contractors; assurances that all members  are included and the information is up to date; and examination of who is  using the data and for what purposes, and the users’ assessment of  reliability. We also examined whether the data tracked through the  services’ systems was subjected to quality control measures, such as  conducting periodic testing of the data against medical records, to ensure  the accuracy and reliability of the data. In addition, we reviewed existing  documentation related to the data sources and interviewed knowledgeable  agency officials about the data. Overall, the reserve components’ data we  assessed regarding compliance with routine medical and dental  examinations and fitness assessments did not accurately reflect the total  population of service members, had limited data quality assurance, and  were unreliable for the purposes of this report; however, we determined  that the Navy Reserve’s medical data were sufficiently reliable for our  purposes. Data from the Navy Reserve’s Medical Readiness Reporting  System were found reliable because Readiness Commands conduct  inspections that include examining the data for accuracy, Medical  Department Representatives verify 10 percent of the updated medical  records after each weekend drill, and the data are reported to the  Commander, Navy Reserve Forces Command biweekly. Further, we did  not assess the reliability of the Marine Corps Reserve’s medical data  because the Marine Corps was in the process of changing from the  Shipboard Automated Medical System, a stand-alone non-Web-based  system, to the Navy Reserve’s system. All reserve components’ physical  fitness data that we reviewed had missing or incomplete information, had  limited data quality controls, or did not accurately reflect the total  population of service members due to limited access to the database.  Therefore, we determined the data to be unreliable for the purposes of  assisting us in determining reserve component members’ compliance with  physical fitness examinations.
To assess DOD’s visibility over reserve components’ health status after  they are called to duty and the care, if any, provided to those deployed  with preexisting conditions, we collected and analyzed information from a  variety of sources throughout DOD. We interviewed officials at the six  reserve component headquarters and officials responsible for mobilizing  the reserve components. We also observed the mobilization of Army  National Guard and Army Reserve members at Fort Bliss, Texas, to obtain  information on their health status during this process. We obtained and  analyzed data provided on medical deployability from the DOD-wide  centralized database on pre- and postdeployment health assessments,  maintained at the Army Medical Surveillance Activity, and discussed  available data with these officials. We also obtained and analyzed data on  Army servicemembers who were held at mobilization stations for medical  reasons from the Army’s medical holdover database (Medical Operational  Data System). Based on our review of databases we used, we determined  that the DOD-provided data were reliable for the purposes of this report.  To address the extent of medical care provided in theater for preexisting  medical conditions, we reviewed the Joint Chiefs of Staff procedures for  Deployment Health Surveillance and Readiness and information provided  by the U.S. Central Command Surgeon’s General office regarding medical  deployment criteria for Operations Enduring Freedom and Iraqi Freedom.  We also collected and reviewed the services’ medical instructions,  memoranda, policies, and medical data. We reviewed several databases for  relevance regarding collecting in theater medical data on preexisting  conditions. Specifically, we obtained information and discussed the  following databases: Joint Medical Workstation, the U.S. Transportation  Command Regulating Command and Control Evacuation System, the Joint  Patient Tracking Application, and the Air Force Institute for Operational  Health Disease Nonbattle Injury database.
However, we did not identify any databases used to collect information on  members that may have had preexisting conditions when deployed. We  also interviewed military medical officials who had served in theater to  obtain information on preexisting conditions of reserve component  members while deployed. In addition to those offices and commands  previously listed, we discussed reserve component medical deployment  policies, medical and physical fitness policies and instructions, and data  regarding medical and physical fitness issues with responsible officials  from:    Joint Chiefs of Staff, J-4 (Logistics), Medical Readiness Division;    U.S. Transportation Command, Scott AFB, Illinois;    U.S. Central Command, MacDill, AFB, Florida; and    Army Medical Surveillance Activity.
U.S. Army Office of the Surgeon General and Commanding General, Army    U.S. Army Center for Health Promotion and Preventive Medicine-Europe;    Army Reserve Unit, Mid-west region;    Walter Reed Army Medical Center; and    Soldier Readiness Processing, Medical Operations, Fort Bliss, Texas.
Navy Reserve Readiness Command Southwest, California;    Navy and Marine Corps Reserve Center, California; and    Navy Branch Medical Clinic, Virginia.
Marine Corps Mobilization Command, Kansas City, Missouri; and    4th Combat Engineer Battalion, Maryland.
Air Force Institute for Operational Health;    142nd Fighter Wing Air National Guard, Portland International Airport,    163rd Air Refueling Wing Air National Guard, March Air Reserve Base,    349th Air Mobility Wing U.S. Air Force Reserve, Travis Air Force Base,    452nd Air Mobility Wing U.S. Air Force Reserve, March Air Reserve Base,  California.
We reviewed Air Force audit and inspection reports. We interviewed  officials with the Air Force Audit Agency regarding its report on the Air  Force’s Individual Deployment Process to obtain a better understanding  of the report’s scope and methodology to assess reserve components’  compliance with medical and dental requirements. We assessed the  reliability of the Air Force Audit Agency’s analyses by (1) reviewing  relevant documentation of their analyses, and (2) interviewing  knowledgeable officials about the audit work and analyses. We  determined the analyses were sufficiently reliable to use as one of the  sources of evidence describing the extent of discrepancies in Air Force  medical and dental records. We also reviewed the Air Force Inspection  Agency’s Health Services reports and its annual analysis reports for  calendar year 2004.
We also found DOD’s Army Medical Surveillance Activity (AMSA)  database and the Army’s Medical Operational Data System (MODS) to be  sufficiently reliable for the purposes of our report due to their data quality  controls and currency. In addition, through our review of existing  information about the systems and the resulting data and through  discussions with cognizant agency officials, we found the data sufficiently  reliable for the purposes of this report.
We interviewed the Chief of AMSA. We discussed the information in the  DOD-wide centralized health assessment database and obtained selected  data from all the reserve and active component members’ pre- and  postdeployment health assessments that were completed from November  2001 through June 2005. Assessments became mandatory for all mobilized  reserve component members on October 25, 2001. The data we obtained  contained predeployment health assessment records for 383,449 reserve  component members and 627,200 for active members. We analyzed the  data that we obtained to determine the categories of medical referrals and  deployability status. We also analyzed data on the self-reported general  health of the reserve component members and compared the data from  predeployment assessments with the data from postdeployment  assessments. All of our analyses compared data across the reserve  components to look for differences or trends.
Further, we reviewed the Army’s medical holdover data in MODS and  found them reliable for our reporting purposes. The Office of the Army  Surgeon General uses MODS to monitor and track the medical holdover  population. The intended use of this system is for the MEDCOM and other  command elements to track active and reserve component  servicemembers in outpatient medical treatment, while still on active duty  status.
We conducted our review from October 2004 through September 2005 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: Comments From the Department of Defense
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Brenda S. Farrell, Assistant  Director; James Bancroft, Larry Bridges, Renee S. Brown, Sara Hackley,  Kenya Jones, Ron La Due Lake, Karen Kemper, Julia Matta, Jen Popovic,  and Nicole Volchko.
section_title: Related GAO Products
paragraphs: Defense Health Care: Improvements Needed in Occupational and  Environmental Health Surveillance during Deployment to Address  Immediate and Longstanding Health Issues. GAO-05-632. Washington,  D.C.: July 19, 2005.
Reserve Forces: An Integrated Plan is Needed to Address Army Reserve  Personnel and Equipment Shortages. GAO-05-660. Washington, D.C.: July  12, 2005.
Defense Health Care: Force Health Protection and Surveillance Policy  Compliance Was Mixed, but Appears Better for Recent Deployments.  GAO-05-120. Washington, D.C.: November 12, 2004.
Military Personnel: DOD Needs to Address Long-term Reserve Force  Availability and Related Mobilization and Demobilization Issues. GAO- 04-1031. Washington, D.C.: September 15, 2004.
Defense Health Care: DOD Needs to Improve Force Health Protection and  Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16, 2003.
Defense Health Care: Quality Assurance Process Needed to Improve  Force Health Protection and Surveillance. GAO-03-1041. Washington,  D.C.: September 19, 2003.
Military Personnel: DOD Needs More Data to Address Financial and  Health Care Issues Affecting Reservists. GAO-03-1004. Washington, D.C.:  September 10, 2003.
Military Personnel: DOD Actions Needed to Improve the Efficiency of  Mobilizations for Reserve Forces. GAO-03-921. Washington, D.C.: August  21, 2003.
Defense Health Care: Army Has Not Consistently Assessed the Health  Status of Early- Deploying Reservists. GAO-03-997T. Washington, D.C.:  July 9, 2003.
Defense Health Care: Army Needs to Assess the Health Status of All  Early-Deploying Reservists. GAO-03-437. Washington, D.C.: April 15, 2003.
Defense Health Care: Most Reservists Have Civilian Health Coverage but  More Assistance Is Needed When TRICARE is Used. GAO-02-829.  Washington, D.C.: September 6, 2002.
VA and Defense Health Care: Military Medical Surveillance Policies in  Place, but Implementation Challenges Remain. GAO-02-478T.  Washington, D.C.: February 27, 2002.
Gender Issues: Improved Guidance and Oversight Are Needed to Ensure  Validity and Equity of Fitness Standards. GAO/NSIAD-99-9. Washington,  D.C.: November 17, 1998.
Defense Health Care: Medical Surveillance Improved Since Gulf War, but  Mixed Results in Bosnia. GAO/NSIAD-97-136. Washington, D.C.: May 13,  1997.
Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet  Medical and Physical Fitness Standards. GAO/NSIAD-94-36. Washington,  D.C.: March 23, 1994.
Operation Desert Storm: War Highlights Need to Address Problem of  Nondeployable Personnel. GAO/NSIAD-92-208. Washington, D.C.: August  31, 1992.
Operation Desert Storm: Full Army Medical Capability Not Achieved.  GAO/NSIAD-92-175. Washington, D.C.: August 18, 1992.
National Guard: Peacetime Training Did Not Adequately Prepare  Combat Brigades for Gulf War. GAO/NSIAD-91-263. Washington, D.C.:  September 24, 1991.