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

Letter

Background

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.

The Military Services’ Requirements for Medical Assessments and Separation Exams

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.

VA’s C&P Exam

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.

Pilot Program for Single Separation Exams

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.

VA and DOD Direction and Guidance for the Establishment of Single Separation Exam Programs at Local Levels

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.

VA and the Military Services Have Established Some Single Separation Exam Programs, But Program Monitoring Is Lacking Despite Plans for Expansion

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.

Single Separation Exams Being Delivered at Some Locations Using Different Approaches

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.

DOD, the Military Services, and VA Do Not Adequately Monitor Single Separation Exam Programs

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.

VA and DOD Leadership Continue to Encourage the Establishment of Single Separation Exam Programs Through a New National Agreement

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.

Infrequent Use of Separation Exams Among Military Services and Other Factors Create Challenges in Establishing Single Separation Exam Programs

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.

The Military Services May Not Benefit from Single Separation Exam Programs Due to Their Infrequent Use of Separation Exams

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.

Some Military Officials Do Not Allocate Installation Resources for Single Separation Exam Programs

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.

Military Staff Turnover Creates Challenges for Maintaining Established Single Separation Exam Programs

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.

Conclusions

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.

Recommendations for Executive Action

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.

Agency Comments

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.

Appendix I: Scope and Methodology

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.

Appendix II: DOD’s Form 2697 – Report of Medical Assessment

Appendix III: DOD’s Form 2808 – Report of Medical Examination

Appendix IV: Comments from the Department of Veterans Affairs and GAO’s Response

The following are GAO’s comments on the VA November 1, 2004, letter.

GAO Comments

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.

Appendix V: Comments from the Department of Defense

Appendix VI: GAO Contacts and Staff Acknowledgments

GAO Contacts

Acknowledgments

In addition to those named above, key contributors to this report were Krister Friday, Cywandra King, Raj Premakumar, Allan Richardson, and Julianna Williams.