VA and DOD Health Care: Efforts to Coordinate a Single Physical Exam Process for Servicemembers Leaving the Military
Published: 2004-11-12T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Servicemembers who leave the military and file disability claims with the Department of Veterans Affairs (VA) may be subject to potentially duplicative physical exams in order to meet requirements of both the Department of Defense's (DOD) military services and VA. To streamline the process for these servicemembers, the military services and VA have attempted to coordinate their physical exam requirements by developing a single separation exam program. In 1998, VA and DOD signed a memorandum of understanding (MOU) instructing local units to establish single separation exam programs. This report examines (1) VA's and the military services' efforts to establish single separation exam programs, and (2) the challenges to establishing single separation exam programs. To obtain this information, GAO interviewed VA and military service officials about establishing the program; evaluated existing programs at selected military installations; and visited selected installations that did not have programs.
section_title: What GAO Found
paragraphs: Since 1998, VA and the military services have collaborated to establish single separation exam programs. However, while we were able to verify that the program was being delivered at some military installations, DOD, its military services, and VA either could not provide information on program locations or provided us with inaccurate information. As of May 2004, VA reported that 28 military installations had single separation exam programs that used one of five basic approaches to deliver an exam that met both VA's and the military services' requirements. However, when we evaluated 8 of the 28 installations, we found that 4 of the installations did not actually have programs in place. Nonetheless, VA and DOD leadership continue to encourage the establishment of single separation exam programs and have recently drafted a new memorandum of agreement (MOA) that is intended to replace the 1998 MOU. Like the original MOU, the draft MOA delegates responsibility for establishing single separation exam programs to local VA and military installations, depending on available resources. However, the draft MOA also contains a specific implementation goal that selected military installations should have single separation exam programs in place by December 31, 2004. This would require implementation at 139 installations--an ambitious plan given the seemingly low rate of program implementation since 1998 and the lack of accurate information on existing programs. Several challenges impede the establishment of single separation exam programs. The predominant challenge is that the military services may not benefit from a program designed to eliminate the need for two separate physical exams because they usually do not require that servicemembers receive a separation exam. As of August 2004, only the Army had a general separation exam requirement for retiring servicemembers. The other military services primarily require separation exams when the servicemember's last physical exam or medical assessment received during active duty is no longer considered current. In fiscal year 2003, only an estimated 13 percent of servicemembers who left the military received a separation exam. Consequently, the military services may not realize resource savings by eliminating or sharing responsibility for this exam. According to some military officials, another challenge to establishing single separation exam programs is that resources, such as facility space and medical personnel, are needed for other priorities, such as ensuring that active duty servicemembers are healthy enough to perform their duties. Additionally, because single separation exam programs require coordination between personnel from both VA and the military services, military staff changes, including those due to routine rotations, can make it difficult to maintain existing programs.

section_title: Letter
paragraphs: Servicemembers who leave the military and file disability claims with the  Department of Veterans Affairs (VA) may be subject to potentially  duplicative physical exams in order to meet requirements of both the  Department of Defense’s (DOD) military services and VA. VA requires  servicemembers applying for service-connected disability compensation to  undergo a physical exam, known as a compensation and pension (C&P)  exam, in order to determine the degree of their disability. During fiscal  year 2003, about 55,500 veterans submitted disability claims to VA within  their first year of leaving the military. Similarly, to document any potential  service-related health conditions or complaints of servicemembers leaving  the military, each of the military services requires a medical assessment,  which consists of a questionnaire and in some cases may include a  physical exam. Moreover, each military service has additional medical  requirements servicemembers must meet when they leave the military— requirements that in some cases include a physical exam, also known as a  separation exam. In fiscal year 2003, about 176,000 servicemembers left  the military and were subject to applicable requirements.
Although the purpose and scope of the physical exams administered by  the military services differ from those administered by VA, the military  services and VA developed a way to coordinate their physical exam  requirements, prevent duplication, and streamline the process for  servicemembers who are leaving the military and filing disability claims. In  1994, VA and the Army initiated a multiyear pilot program that concluded  that a program consisting of one physical exam could be designed to meet  both the military services’ requirements for servicemembers leaving the  military and VA’s requirements for determining disability. VA and the Army  also concluded that such a program would encourage a more efficient use  of VA and military resources, improve the timeliness of disability claims  processing, and offer convenience to servicemembers. Based on the  findings of the pilot program, in 1998, VA’s Under Secretary for Health and  DOD’s Acting Assistant Secretary of Defense for Health Affairs signed a  memorandum of understanding (MOU) that directed local VA offices and  military medical facilities to work together to establish single separation  exam programs.
To target servicemembers who are preparing to leave the military and  intend to file a disability claim, VA is working with the military services to  establish single separation exam programs at military installations that  have a Benefits Delivery at Discharge (BDD) program. The BDD program  is a joint VA/DOD initiative designed to streamline servicemembers’  transition from active duty to veterans’ status. At military installations  with BDD programs, VA personnel educate servicemembers about VA  disability benefits and help them apply for benefits before they leave  military service—a process that is otherwise initiated after  servicemembers leave the military. BDD programs, which are designed for  servicemembers who have between 60 and 180 days remaining on active  duty, are usually located at military installations that have large numbers  of servicemembers leaving the military. At BDD sites that have single  separation exam programs, servicemembers typically receive a single  separation exam after they submit their disability claims paperwork. As of  August 2004, VA reported there were BDD programs at 139 military  installations.
You asked us to provide information on how VA and DOD’s military  services are collaborating to provide single separation exams for  servicemembers who leave the military and intend to apply for service- connected disability compensation. This report examines (1) VA’s and the  military services’ efforts to establish single separation exam programs, and  (2) the challenges to establishing single separation exam programs.
To identify VA’s and the military services’ efforts to establish single  separation exam programs, we obtained information on VA’s and the  military services’ medical requirements involving physical exams or other  medical evaluations, and we interviewed officials from the Office of the  Assistant Secretary of Defense for Health Affairs, the military services’  Surgeons General, and VA. We also obtained a list of military installations  that VA reported as having single separation exam programs. We used this  list to select eight installations that represented each branch of the  military services to further evaluate VA’s and the military services’ efforts  to establish these programs. We did not verify whether the remaining  installations on VA’s list had operational programs in place, and we are  only reporting on how programs were operating at these eight selected  installations. To identify the challenges to establishing single separation  exam programs, we interviewed VA officials from 15 locations whose  regions included military installations with at least 500 servicemembers  who left the military in fiscal year 2003. We also visited seven military  installations that were not administering single separation exam programs  to learn why such programs were not in place. These seven installations  represented each of the military services and had at least 500  servicemembers leaving the military during fiscal year 2003. In addition,  we obtained data on the number of disability claims filed, the number of  separations from the military, the estimated number of separation exams  provided by the military services, and the average costs of VA and DOD  physical exams. We assessed the reliability of these data and determined  that they were sufficiently reliable for our purposes. Our work was  performed from January 2004 through November 2004 in accordance with  generally accepted government auditing standards. For more details on  our scope and methodology, see appendix I.
subsections: section_title: Background
paragraphs: The military services and VA have medical requirements that  servicemembers must meet when leaving the military and applying for VA  disability compensation. These requirements include a medical  assessment; a service-specific separation exam, which is given to some  servicemembers; and a VA C&P exam. The single separation exam  program is designed to provide a single physical exam that can be used to  meet the physical exam requirements of the military services and VA.
subsections: section_title: The Military Services’ Requirements for Medical Assessments and Separation Exams
paragraphs: In response to a 1994 memorandum from the Assistant Secretary of  Defense for Health Affairs, all of the military services require a medical  assessment of all servicemembers leaving the military, including those that  retire or complete their tour of active duty. This assessment, which is  used to evaluate and document the health of these servicemembers,  consists of a standard two-page questionnaire asking servicemembers  about their overall health, medical and dental histories, current  medications, and other health-related topics. (See app. II for DOD’s  medical assessment form—DD Form 2697.) Military medical personnel,  who could include a physician, a physician’s assistant, or a nurse  practitioner, are required to review the questionnaire with the  servicemember. If the questionnaire indicates the presence of an illness,  injury, or other medical problem, the reviewer is required to ensure that  the servicemember’s medical or dental records document the problem. In  addition, depending on the servicemember’s responses or based on the  reviewer’s judgment that additional information is needed, the health  assessment could result in a physical exam—one focused on a particular  health issue or issues in order to supplement information disclosed on the  questionnaire. Furthermore, the medical assessment asks if the  servicemember intends to file a claim for disability with VA.   Servicemembers who answer “yes” on the assessment form will be given a  clinically appropriate assessment or exam if the servicemember’s last  physical exam received during active duty is more than 12 months old or if  new symptoms have appeared since the last active duty exam.
In addition, the Army, Navy, Air Force, and Marines require some of their  servicemembers to undergo separation exams when they leave the  military. Separation exams consist of a clinical evaluation by a medical  provider and could include various diagnostic tests, such as a urinalysis, a  hearing test, and a vision test. Separation exams, as well as other physical  exams the military services conduct, are documented on a three-page  standard DOD form. (See app. III for DOD’s report of medical  examination—DD Form 2808.) According to DOD, the average cost for a  physical exam given by the military services is about $125, exclusive of  any diagnostic tests that may also be conducted.
The requirements determining which servicemembers must receive  separation exams vary by military service and other factors. The Army  requires that its retirees receive separation exams, although the Army does  not usually require this for servicemembers who are completing their tours  of active duty. The other military services do not require separation exams  for most servicemembers, except for those whose last physical exam or  assessment they received during active duty is out of date. (See table 1 for  each military service’s medical evaluation requirements.) Further, all of  the military services also require separation exams for certain  occupational specialties. For example, the military services require  separation exams for servicemembers who have worked with hazardous  materials. Finally, any servicemember can request and receive a  separation exam.
Requirements for separation exams may be affected by planned changes to  physical exam requirements for active duty servicemembers. The Army  and Navy plan to change their physical exam requirements for  servicemembers during active duty—replacing routine physical exams  with periodic health assessments, thereby moving closer to the Air Force’s  requirements for active duty servicemembers. In September 2003, the  Armed Forces Epidemiology Board (AFEB) issued a report that  concluded that annual health assessments, as currently administered by  the Air Force to active duty servicemembers, should replace routine  physical exams. According to their Surgeon General representatives, the  Army and the Navy intend to change their regulations relating to periodic  physical exams and to adopt the recommendations offered by the AFEB  by 2005. This shift in requirements is in line with recommendations of the  U.S. Preventive Services Task Force and many other medical  organizations, which no longer advocate routine physical exams for  adults—recommending instead a more selective approach to detecting and  preventing health problems.
section_title: VA’s C&P Exam
paragraphs: Some servicemembers who leave the military file for VA disability  benefits, which could include priority access to VA health care as well as  monthly payments for disabilities, diseases, or injuries incurred or  aggravated during active military service. VA requires evidence of military  service to confirm eligibility for these benefits, and the department uses  the C&P exam to establish a disability rating, which helps determine the  amount of compensation a veteran receives. Veterans retain the option of  initiating claims at any time after leaving the military, even if they did not  state their intention to do so on the medical assessment form completed  when they left military service.
A VA C&P exam is a physical exam used to determine a veteran’s degree of  disability in support of claims for service-connected disability  compensation. The exam obtains information on the veteran’s medical  history and includes diagnostic and clinical tests, the scope of which  depend on what disabilities the veteran claims. For example, if a veteran  claims a disability for a knee injury, VA would require a comprehensive  orthopedic exam to determine the percent of movement that has been lost  due to the knee injury. Veterans may claim multiple disabilities—all of  which must be evaluated for disability rating purposes.
In general, VA’s C&P exam is more comprehensive and detailed than the  military services’ separation exams, as military service exams are intended  to document continued fitness for duty, whereas the purpose of the VA  C&P exam is to document disability or loss of function regardless of its  impact on fitness for duty. VA physicians who conduct the C&P exam  must evaluate the extent of a veteran’s physical limitations and determine  their impact on the veteran’s future employment for compensation  purposes. VA physicians usually conduct C&P exams at VA Medical  Centers, although since 1996 VA has had authority to use civilian  physicians to provide C&P exams at 10 VA regional offices. In addition,  VA physicians may provide C&P exams at some military medical facilities.  According to VA officials, the average cost of VA’s C&P exam, exclusive of  any diagnostic tests, is about $400 when conducted by either VA or by VA’s  contractor.
section_title: Pilot Program for Single Separation Exams
paragraphs: In 1994, the Army and VA jointly initiated a pilot program for single  separation exams at three Army installations. Each of the installations  used a different approach when implementing the exam.
At Fort Hood, Texas, a VA physician performed single separation exams at  the Army’s military treatment facility.
At Fort Knox, Kentucky, a sequential approach was used in which Army  personnel performed some preliminary work, such as lab tests and optical  exams, for servicemembers at the installation. Servicemembers were then  transported to a local VA medical center, where VA physicians completed  the single separation exams.
At Fort Lewis, Washington, an Army physician performed the single  separation exams at the military installation.
The 1997 report on the pilot programs concluded that all of the  approaches for single separation exams were successful and that, overall,  they eliminated redundant physical exams and medical procedures,  decreased resource expenditures, increased the timeliness of VA’s  disability rating decisions, and improved servicemembers’ satisfaction.  The report also recommended that single separation exam programs be  expanded to include all military services.
section_title: VA and DOD Direction and Guidance for the Establishment of Single Separation Exam Programs at Local Levels
paragraphs: Based on the findings of the single separation exam pilot, VA’s Under  Secretary for Health and DOD’s Acting Assistant Secretary of Defense for  Health Affairs signed an MOU in 1998 directing local VA offices and  military medical facilities to negotiate and implement individual MOUs for  single separation exam programs. According to the MOU, VA and the  military services should optimize available resources, including the use of  both military and VA facilities and staff as appropriate. For example,  because a servicemember applying for VA benefits would receive a single  physical exam that meets VA C&P exam requirements—which are usually  more extensive than the military services’ separation exam requirements— the MOU envisioned that VA medical personnel would perform most of the  single separation exams. It also stated that the military services would  provide VA with servicemembers’ medical records and lab and test results  from active duty in order to avoid duplicative testing. Finally, the MOU  acknowledged that in implementing single separation exam programs,  negotiations between local VA and military officials would be necessary,  because military installations and local VA offices and hospitals face  resource limitations and competing mission priorities. These local level  negotiations would be documented in individual MOUs.
To implement the 1998 MOU, both VA and DOD issued department- specific guidance. In January 1998, both VA’s Under Secretary for Health  and Under Secretary for Benefits distributed guidelines to VA regional  offices and medical centers about completing the single separation exams  in cooperation with the military services. In September 1998, DOD’s  Assistant Secretary of Defense for Health Affairs issued a policy to the  Assistant Secretaries for the Army, Navy, and Air Force stating that  servicemembers who leave the military and intend to file a claim for VA  disability benefits should undergo a single physical exam for the military  services and VA.
section_title: VA and the Military Services Have Established Some Single Separation Exam Programs, But Program Monitoring Is Lacking Despite Plans for Expansion
paragraphs: Since 1998, VA and the military services have collaborated to establish  single separation exam programs using various approaches to deliver the  exams, including those used in the original pilot program. However, while  we were able to verify that the exams were being delivered at some  installations, DOD, its military services, and VA either could not provide  information or provided us with inaccurate information on program sites.  Although VA reported that 28 of 139 BDD sites had programs in place as of  May 2004, we found that 4 of the 8 sites we evaluated from VA’s list did not  actually have a program in place. Nonetheless, VA and DOD leadership  continue to encourage the establishment of single separation exam  programs and have drafted a new MOA that contains a specific  implementation goal to have programs in place at all of the BDD sites by  December 31, 2004—an ambitious goal given the seemingly low rate of  program implementation since 1998 and the lack of accurate information  on existing programs.
subsections: section_title: Single Separation Exams Being Delivered at Some Locations Using Different Approaches
paragraphs: VA reported that as of May 2004, 28 of the 139 BDD sites had operating  single separation exam programs. At these sites, VA officials told us, local  VA and military officials have implemented the program using one of five  approaches that met both the military services’ and VA’s requirements  without duplication of effort. Three of the five approaches were developed  during the 1994 pilot program—(1) military physicians providing the  exams at military treatment facilities, (2) VA physicians providing the  exams at military treatment facilities, and (3) a sequential approach  wherein VA and the military service shared the responsibility of  conducting consecutive components of a physical exam. In addition, VA  officials reported a fourth approach that was being used, in which VA  physicians delivered the single separation exam at VA hospitals, and a fifth  approach, in which VA used a civilian contractor to deliver the exams.
We evaluated the operation of the single separation exam programs at four  of the military installations VA reported as having collectively conducted  over 1,400 exams in 2003. These installations were conducting single  separation exams using two of the approaches—either with VA’s  contractor conducting the physical exam or as a sequential approach. (See  table 2.) Overall, VA and military officials told us that both approaches  worked in places where military officials and VA officials collaborated  well together.
At two Army installations—Fort Stewart and Fort Eustis—we found that  VA used its civilian contractor to conduct C&P exams, which the Army  then used to meet its separation exam requirements for servicemembers  leaving the military. At the Fort Drum Army installation and Naval Station  Mayport, local VA and military service officials collaborated to implement  a sequential approach. At Fort Drum, the Army starts the single separation  exam process by conducting hearing, vision, and other diagnostic testing.  A VA physician subsequently completes the actual physical exam at the  installation, which is then incorporated in the servicemember’s medical  record. At Naval Station Mayport, a Navy corpsman starts the sequential  process by reviewing the servicemember’s medical history, initiating  appropriate paperwork, and scheduling the servicemember for an  appointment with a VA physician. The VA physician then conducts a VA  C&P exam at the installation and completes the paperwork to meet the  Navy’s separation requirements.
section_title: DOD, the Military Services, and VA Do Not Adequately Monitor Single Separation Exam Programs
paragraphs: DOD and its military services do not adequately monitor where single  separation exam programs have been established. DOD does not maintain  servicewide information on the locations where single separation exam  programs are operating. While the Army and the Air Force each provided a  list of installations where officials claimed single separation exam  programs were established, both lists included installations that we  verified as not having a program in place. A Navy official told us that  although the Navy attempted to identify the locations of single separation  exam programs, its information was not accurate.
In addition, while VA maintains a list of single separation exam programs,  this list was not up to date. At our request, VA attempted to update their  list and reported to us that in May 2004, 28 military installations with BDD  programs also had single separation exam programs. At these sites, VA  reported that over 11,000 single separation exams had been conducted in  2003. However, when we evaluated programs at 8 of these installations, we  found that 4 of the installations did not actually have programs in place.  (See table 3.)
At these four military installations, the 2,075 exams reported as single  separation exams were actually VA C&P exams that were used only by VA  and not by the military services. We obtained the following information  about these installations.
At Fort Lee, local Army and VA officials told us that a single separation  exam program was in place prior to our site visit. However, during a joint  discussion with us, they realized that the local MOU, which was signed in  April 2001, was not being followed and that the single separation exam  program was no longer in operation. Nonetheless, local VA officials  responsible for reporting on the program were unaware that the program  was no longer operational.
At Little Rock Air Force Base, we found that a single separation exam  program was not in place even though there was an MOU, which local VA  officials told us was signed in May 1998. During our initial discussions,  local VA officials told us that the program was in operation. However, as  they responded to VA headquarter’s inquiry to update their list of  installations with single separation exam programs for us, local officials  realized that the program was not in operation and had never existed  despite the signed MOU. Nonetheless, this site was still included on the  updated list of installations that VA provided to us.
At Pope Air Force Base, local military officials told us that no single  separation exam program was in place. Furthermore, a local VA official  said that no MOU had been signed for the program at this installation.  However, despite this, local VA officials mistakenly believed that  installation officials were using the VA C&P exams to meet their  separation requirements and that, as a result, single separation exams  were being provided.
Finally, at Marine Camp Lejeune, local military and VA officials told us  that no single separation exams were being conducted even though there  was an MOU, which was signed in 2001. When we met with the  installation’s hospital commander, he told us that the hospital was not  participating in the single separation exam program, and he was unaware  of the existence of the MOU for this program. We also met with military  officials at the Hadnot Branch Clinic, the installation’s busiest clinic in  terms of separation physicals, and at the time of our review, this clinic was  also not participating in the single separation exam program. Furthermore,  local VA officials told us that they realized that the program was not in  operation at the time of our visit—even though it was included on the list  that VA updated for us.
We also identified another military installation that had a single separation  exam program—even though it was not included in VA’s list of  installations with these programs. Regional VA officials told us—and we  confirmed—that an MOU for a single separation exam program had been  implemented at MacDill Air Force Base, Florida. At this installation, local  military officials reported that 516 single separation exams were  conducted in 2003. According to local VA and military officials, this  installation employs a sequential approach wherein VA uses medical  information from Air Force health assessments as well as any diagnostic  tests that may have been conducted in conjunction with them to help  complete C&P exams for servicemembers applying for VA disability  compensation.
section_title: VA and DOD Leadership Continue to Encourage the Establishment of Single Separation Exam Programs Through a New National Agreement
paragraphs: As part of an overarching effort to streamline servicemembers’ transition  from active duty to veterans’ status, VA and DOD continue to encourage  the establishment of single separation exam programs and have drafted a  national MOA, which is intended to supercede the 1998 MOU. Unlike the  original MOU, the draft MOA contains a specific implementation goal— that VA and the military services establish single separation exam  programs at each of the installations with BDD programs by December 31,  2004. The draft MOA also provides more detail about how the military  services and VA will share servicemembers’ medical information to  eliminate duplication of effort. For example, the MOA states that the  military services will share the medical assessment forms along with any  completed medical exam reports and pertinent medical test results with  VA. Similarly, the MOA specifies that when VA conducts its C&P exam of  servicemembers before they leave the military, this information should be  documented in servicemembers’ military medical records. According to  VA officials, the draft MOA extends the eligibility period for  servicemembers to participate in the program by eliminating the previous  requirement that servicemembers had to have a minimum number of  days—usually 60—remaining on active duty. As a result, servicemembers  may participate in the program when they have 180 days or less remaining  on active duty.
Aside from some specific additions, the general guidance in the draft MOA  is consistent with the 1998 MOU. For example, the draft MOA delegates  responsibility for establishing single separation exam programs to local VA  and military installations, based on the medical resources—including  physicians, laboratory facilities, examination rooms, and support staff— available to conduct the exams and perform any additional testing. The  MOA also continues to provide flexibility that allows local officials to  determine how the exams will be delivered—by VA, by VA’s contractor, or  by DOD.
According to VA, the draft MOA is expected to be signed by DOD’s Under  Secretary of Defense for Personnel and Readiness and the Deputy  Secretary of VA in November 2004. In contrast, the 1998 MOU was signed  at lower levels of leadership within each department—DOD’s Acting  Assistant Secretary of Defense for Health Affairs, who reports to the  Under Secretary of Defense for Personnel and Readiness, and VA’s Under  Secretary for Health, who reports to the Deputy Secretary of VA. Both VA  and DOD officials told us that endorsement for the new draft MOA from  higher-level leadership within the departments should facilitate the  establishment of single separation exam programs. However, it will be  difficult to determine where the program needs to be implemented  without accurate program information with which to oversee and monitor  these efforts—a critical deficiency in light of the MOA’s ambitious goal to  establish the program at all BDD sites by December 31, 2004, and given the  seemingly low rate of implementation at the 139 BDD sites.
section_title: Infrequent Use of Separation Exams Among Military Services and Other Factors Create Challenges in Establishing Single Separation Exam Programs
paragraphs: Several challenges impact the establishment of single separation exam  programs. The primary challenge is that the military services do not  usually require servicemembers to undergo a separation exam before  leaving the military. In fiscal year 2003, the military services administered  separation exams for an estimated one-eighth of servicemembers who left  the military. Consequently, although individual servicemembers may  benefit from single separation exams, the military services may not realize  benefits from resource savings through eliminating or sharing  responsibility for the separation exams. Another challenge to establishing  these programs is that some military officials told us that they need their  resources, such as space and medical personnel, for other priorities,  including ensuring the health of active duty servicemembers. Furthermore,  VA officials told us that because single separation exam programs require  coordination between personnel from both VA and the military services,  existing programs can be difficult to maintain because of routine rotations  of military staff to different installations.
subsections: section_title: The Military Services May Not Benefit from Single Separation Exam Programs Due to Their Infrequent Use of Separation Exams
paragraphs: Despite increased convenience for individual servicemembers, the military  services may not benefit from single separation exam programs—designed  to eliminate the need for two separate exams—because the military  services usually do not require servicemembers who are leaving the  military to have separation exams. In fiscal year 2003, the military services  administered separation exams to an estimated 23,000, or one-eighth, of  the servicemembers who left the military that fiscal year. However, this  estimate may undercount the number of servicemembers who received  separation exams. (See fig. 1.)
Because the military services do not usually require separation exams, it is  unlikely that servicemembers will receive physical exams from both the  military and VA. At two Army installations without single separation exam  programs, we found that relatively few servicemembers had received both  a C&P exam from VA and a separation exam from the Army. From June  2002 through May 2004, 810 servicemembers received a VA C&P exam at  Fort Gordon, and of these, 121 soldiers—about 15 percent—had also  received a separation exam from the Army. Similarly, during June 2003  through May 2004, 874 servicemembers received a VA C&P exam at Fort  Bragg, and of these only 38—about 4 percent—had also received a  separation exam from the Army. Because the Army is the only military  service to require separation exams for all retirees, we expected that the  Army’s servicemembers were more likely those of the other military  services to receive two physical exams. However, the small percentage of  servicemembers that received both VA C&P exams and Army separation  exams at these two installations suggests that the potential for resource  savings by having single separation exams is likely small.
In addition, some Air Force officials told us that they did not see a need to  participate in single separation exam programs because of their health  assessment requirements. For example, at Little Rock Air Force Base,  officials told us that because the Air Force does not routinely require  separation physicals for most servicemembers, it was not practical to use  VA’s C&P physicals as single separation exams. The officials explained  that VA’s C&P exams obtain more information than needed to meet the Air  Force’s health assessment requirement and that using VA’s exam as a  single separation exam would not be an efficient use of resources. The  officials said that it would take military medical personnel too much time  to review the VA C&P exams to identify the information the Air Force  required. Similarly, officials at other Air Force installations we visited— Hurlburt Field, Langley Air Force Base, and Eglin Air Force Base—agreed  that they would not benefit from a single separation exam program.  However, we did find one Air Force installation—MacDill Air Force  Base—where a single separation exam program was operational,  demonstrating the feasibility of Air Force installations participating in  single separation exam programs.
section_title: Some Military Officials Do Not Allocate Installation Resources for Single Separation Exam Programs
paragraphs: Some military officials told us that they use their installations’ resources  for other priorities than establishing single separation exam programs.  Although the 1998 MOU encouraged the establishment of these programs  for servicemembers leaving the military and filing VA disability claims,  some local military officials told us that their installations did not  currently have these programs because they decided to use available  resources to support other efforts, such as conducting wartime training  and ensuring that active duty servicemembers are healthy enough to  perform their duties. For example, when we visited Fort Bragg we learned  that the commander had initially agreed to provide space at his installation  for a single separation exam program. However, the same space was  committed to more than one function, and when the final allocation  decision was made, other mission needs took priority. In addition,  Nebraska VA officials told us that an existing single separation exam  program was eliminated at Offutt Air Force Base because military medical  personnel assigned to help VA physicians administer the exams were  needed to focus on the health of active duty servicemembers at the  installation.
In addition, military officials explained that administering single  separation exams that include VA’s C&P protocols are more time intensive  for their staff and can involve more testing than the military’s separation  exams. As a result, military officials are reluctant to assign resources,  including facilities and staff, to this effort. Further, military officials  explained that expending time and resources to train military physicians  to administer single separation exams is not worthwhile because these  physicians periodically rotate to other locations to fulfill their active duty  responsibilities so other military physicians would have to be trained as  replacements.
section_title: Military Staff Turnover Creates Challenges for Maintaining Established Single Separation Exam Programs
paragraphs: Because single separation exam programs require coordination between  personnel from both VA and the military services, staff changes or  turnover can make it difficult to maintain existing programs. For example,  during our visit to the Army’s Fort Lee, we found that the installation’s  single separation program had stopped operating because of staff  turnover. When the program was in operation, a sequential approach was  used in which Army personnel conducted the initial part of the exams,  which included medical history and diagnostic testing, and then shared  servicemembers’ medical records with VA personnel at the VA hospital,  where the single separation exams were completed. According to VA and  Army officials, after the Army personnel changed, the installation no  longer provided VA with the medical records.
Further, VA officials told us that maintaining joint VA and DOD  programs—such as single separation exam programs—is challenged by  the fact that military staff, including commanders, frequently rotate.  According to VA officials, some commanders do not want to continue  agreements made by their predecessors so single separation programs  must be renegotiated when the commands change. However, VA officials  told us that the new draft MOA should help alleviate this challenge to  program establishment because it states that local agreements between  military medical facilities and VA regional offices will continue to be  honored when leadership on either side changes.
section_title: Conclusions
paragraphs: Since 1998, VA and DOD’s military services have attempted to establish  single separation exam programs in order to prevent duplication and  streamline the process for servicemembers who are leaving the military  and intend to file a disability claim with VA. However, according to VA,  fewer than 30 out of 139 military installations with BDD programs had  single separation exam programs as of May 2004. To encourage more  widespread program establishment, the departments have drafted a new  national MOA with the goal of having programs in place at all BDD sites by  December 31, 2004. Increasing the single separation exam program to all  BDD sites will allow more servicemembers to benefit from its  convenience. Yet, given the seemingly low rate of program implementation  since 1998 and the challenges we identified in establishing and maintaining  the program, it is unlikely that the programs will be established at about  100 more sites less than 2 months after the MOA becomes effective.  Consequently, both departments will need to monitor program  implementation to ensure that the new MOA is put into practice— especially since local agreements for single separation exam programs  have not always resulted in the establishment and operation of such  programs.
section_title: Recommendations for Executive Action
paragraphs: To determine where single separation exam programs are established and  operating, we recommend that the Secretary of VA and the Secretary of  Defense develop systems to monitor and track the progress of VA regional  offices and military installations in implementing these programs at BDD  sites.
section_title: Agency Comments
paragraphs: We requested comments on a draft of this report from VA and DOD. Both  agencies provided written comments that are reprinted in appendices IV  and V. VA and DOD concurred with the report’s findings and  recommendation. DOD also provided technical comments that we  incorporated where appropriate.
In commenting on this draft, VA stated that it has actions underway or  planned that meet the intent of our recommendation. First, it has  established an inspection process of BDD sites to determine compliance  with procedures. In addition, VA noted that it has worked with DOD to  revise the MOA for single separation exam programs and that it has  instructed its regional offices to begin working with military treatment  facilities to implement its provisions. Finally, VA said that VA’s and DOD’s  joint strategic plan for fiscal year 2005 will include substantive  performance measures to monitor the process of moving from active duty  to veteran status through a streamlined benefits delivery process.
In their written comments, DOD recognized the importance of a shared  DOD and VA separation process and its benefits to servicemembers and  noted the fact that both departments are working on an MOA to further  encourage single separation exams. DOD also stated that the capability to  monitor and track the progress of single separation exams has been  hampered by the lack of a shared VA and DOD information technology  system. However, DOD reported that VA is developing automated  reporting tools and will be doing on-site visits to BDD sites, and VA and  DOD will share information gathered from this system and site visits.
We are sending copies of this report to the Secretary of Defense, the  Secretary of Veterans Affairs, appropriate congressional committees, and  other interested parties. We will also make copies available to others upon  request. In addition, the report is available at no charge on the GAO Web  site at http://www.gao.gov. If you or your staff have questions about this  report, please contact me at (202) 512-7119. Other contacts and staff  acknowledgments are listed in appendix VI.
section_title: Appendix I: Scope and Methodology
paragraphs: To identify efforts by the Department of Veterans Affairs (VA) and the  military services to establish single separation exam programs for  servicemembers who plan to file VA disability claims, we reviewed  pertinent legislation and obtained VA’s requirements for compensation  and pension (C&P) exams. We also obtained service-specific requirements  for periodic physical exams and health assessments and evaluations,  especially those requirements pertaining to separating and retiring  servicemembers. We obtained and reviewed relevant documentation  about both departments’ efforts to establish single separation exam  programs. We also interviewed officials from the office of the Assistant  Secretary of Defense for Health Affairs, the military services’ Surgeons  General, and VA. In addition, we obtained VA’s data on the number of  disability claims and the cost data associated with conducting military  physical exams and VA C&P exams. Based on our review of these data and  subsequent discussions with agency officials, we determined that these  data were sufficiently reliable for the purposes of this report.
We obtained a list of 28 military installations that VA officials had  identified as having single separation exam programs through a survey of  their Benefits Delivery at Discharge (BDD) sites. We used this list to select  8 installations to learn how their programs operated. We did not verify  whether the remaining 20 installations had single separation exam  programs because such verification would have required a full evaluation  of actual program operations at these locations. We also did not verify the  number of installations with BDD sites or the numbers of single separation  exams VA reported for these military installations. We selected  installations that represented each of VA’s reported approaches for  operating the single exam program—VA physicians conducting the exam  at military installations, VA physicians conducting the exam at VA medical  centers, Department of Defense (DOD) physicians conducting the exam,  VA and DOD using a sequential approach for the exam, and VA’s civilian  contractors delivering the exam. The installations we selected represented  each of the four branches of the military service—Army, Navy, Air Force,  and Marines—and all but one had more than 500 servicemembers leave in  fiscal year 2003. We obtained the separation data from the Defense  Manpower Data Centers’ (DMDC) Active Duty Military Personnel file on  the number of servicemembers who left the military from various  separation locations during fiscal year 2003. To assess the reliability of  these data, we conducted logic tests to identify inconsistencies, reviewed  existing information about it and the system that produced it, and  interviewed an agency official who was knowledgeable about the data. We  determined the data to be sufficiently reliable for the purposes of this  report.
From VA’s list we visited seven military installations—Marine Corps Base  Camp Lejeune, North Carolina; Fort Eustis, Virginia; Fort Lee, Virginia;  Fort Stewart, Georgia; Little Rock Air Force Base, Arkansas; Naval Station  Mayport, Florida; and Pope Air Force Base, North Carolina. We also  conducted telephone interviews with medical command and VA officials  associated with Ft. Drum, New York. Further, we conducted a telephone  interview with military and VA officials from MacDill Air Force Base,  Florida, which has a single separation exam program but was not on VA’s  list. At the installations we visited or contacted, we spoke with medical  command officials and with VA officials responsible for the single  separation exam program to discuss the different types of local  agreements and procedures used for delivering single separation exams.
We also reviewed the draft memorandum of agreement (MOA) related to  single separation exam programs and interviewed officials from VA, the  Office of the Assistant Secretary of Defense for Health Affairs, and the  services’ Surgeons General to obtain information on VA and DOD officials’  efforts to draft and implement this MOA.
To obtain information on the challenges associated with establishing  single separation exam programs, we identified and visited military  installations that did not have single separation exam programs. We used  DMDC’s separation data for fiscal year 2003 to identify installations  representing each of the military services—Army, Navy, Air Force, and  Marines—that had more than 500 separations and were not reported by VA  as having a single separation exam program. We also visited installations  that were located in the same VA regions as installations we visited that  VA had reported as having single separation exam programs. The seven  military installations we visited were Marine Corps Air Station Cherry  Point, North Carolina; Eglin Air Force Base, Florida; Fort Bragg, North  Carolina; Fort Gordon, Georgia; Hurlbert Field Air Base, Florida; Langley  Air Force Base, Virginia; and Naval Station Norfolk, Virginia. At these  installations, we interviewed medical command officials and VA officials  to learn whether single separation exam programs had been considered  and what the challenges were to establishing them. For the two Army  installations included in these seven selected installations—Fort Bragg,  North Carolina and Fort Gordon, Georgia—we obtained both the  separation exam data and C&P exam data for each installation to  determine how many separating servicemembers from each installation  received both an Army separation exam and a VA C&P exam. We chose  Army installations for this analysis because duplicate service and C&P  exams were more likely to occur due to the Army’s requirement that  retirees receive a physical exam. After our review of the documentation  and subsequent discussions with agency officials, we concluded that these  data were sufficiently reliable for the purposes of this report. We also  reviewed DOD’s separation exam data and discussed it with an agency  official. Based on this information, we concluded that these data were  sufficiently reliable for the purposes of this report although it may  understate the number of separation exams because some may have been  identified more generally as physical exams.
To obtain additional information on the challenges to establishing single  separation exam programs, we called or visited VA regional offices in 16  locations—Arkansas, California (three regions), Georgia, Florida,  Kentucky, Nebraska, New York, North Carolina, Oklahoma, South  Carolina, Texas (two regions), Virginia, and Washington—and talked with  officials responsible for initiating and implementing these programs. We  selected six of these regional offices because they were already involved  in establishing single separation exam programs at the eight military  installations we selected from VA’s list. We asked these officials about the  challenges they encountered when trying to establish these programs at  other installations in their regions. We also interviewed officials from the  three VA regional offices involved in the pilot program for single  separation exams. We talked with officials from seven additional regional  offices that had responsibility for military installations with more than 500  separations during fiscal year 2003 to determine how they established  programs in their regions and problems they encountered when programs  could not be established.
We performed our work from January 2004 through November 2004 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: DOD’s Form 2697 – Report of Medical Assessment
section_title: Appendix III: DOD’s Form 2808 – Report of Medical Examination
section_title: Appendix IV: Comments from the Department of Veterans Affairs and GAO’s Response
paragraphs: The following are GAO’s comments on the VA November 1, 2004, letter.
subsections: section_title: GAO Comments
paragraphs: 1. We used VA’s May 2004 updated list to select our sites, and we found that  it contained information that was both incomplete and inaccurate. The list  included installations where we did not find single separation exam  programs. It also omitted one installation where we found a single  separation exam program.  2. We agree that individual servicemembers will benefit from single  separation exam programs and have added information to the body of the  report to reflect this.  3. We modified this statement as follows: “In general, VA’s C&P exam is  more comprehensive and detailed than the military services’ separation  exams, as military service exams are intended to document continued  fitness for duty, whereas the purpose of the VA C&P exam is to document  disability or loss of function regardless of its impact on fitness for duty.”  4. Although VA believed the C&P exam was being used for separation  purposes at Pope Air Force Base, it was not. As we reported, VA and DOD  had not signed an MOU for a single separation exam program at this  installation, and the Air Force was clear that it was not using the C&P exam  for separation purposes.  5. While Camp Lejeune’s Hadnot Branch Clinic may currently be  conducting single separation exams, at the time of our visit in June 2004,  the physician at the Hadnot Clinic told us he was not using VA’s C&P exams  for servicemembers’ separation exams. In September 2004, we confirmed  this information with the clinic physician.
section_title: Appendix V: Comments from the Department of Defense
section_title: Appendix VI: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgments
paragraphs: In addition to those named above, key contributors to this report were  Krister Friday, Cywandra King, Raj Premakumar, Allan Richardson, and  Julianna Williams.