Defense Health Care: Army Needs to Assess the Health Status of All Early-Deploying Reservists
Released: 2003-04-15T00:00:00

Letter

Background

In recent years, reservists have regularly been called on to augment the capabilities of the active-duty forces. The Army is increasingly relying on its reserve forces to provide assistance with military conflicts and peacekeeping missions. As of April 2003, approximately 148,000 reservists from the Army National Guard and the U.S. Army Reserve were mobilized to active duty positions. In addition, other reservists are serving throughout the world in peacekeeping missions in the Balkans, Africa, Latin America, and the Pacific Rim. The involvement of reservists in military operations of all sizes, from small humanitarian missions to major theater wars, will likely continue under the military’s current war fighting strategy and its peacetime support operations.

The Army has designated some Army National Guard and U.S. Army Reserve units and individuals as early-deploying reservists to ensure that forces are available to respond rapidly to an unexpected event or for any other need. Usually, those designated as early-deploying reservists would be the first troops mobilized if two major ground wars were underway concurrently. The units and individual reservists designated as early- deploying reservists change as the missions or war plans change. The Army estimates that of its 560,000 reservists, approximately 90,000 are reservists who have been individually categorized as early-deploying reservists or are reservists who are assigned to Army National Guard and U.S. Army Reserve units that have been designated as early-deploying units.

The Army must comply with the following six statutory requirements that are designed to help ensure the medical and dental readiness of its early- deploying reservists.

All reservists including early-deployers are required to have a 5-year physical examination, and complete an annual certificate of physical condition.

All early-deploying reservists are also required to have a biennial physical examination if over age 40, an annual medical screening, an annual dental screening, and dental treatment.

Army regulations state that the 5- and 2-year physical examinations are designed to provide the information needed to identify health risks, suggest lifestyle modifications, and initiate treatment of illnesses. While the two examinations are similar, the biennial examination for early- deploying reservists over age 40 contains additional age-specific screenings such as a prostate examination, a prostate-specific antigen test, and a fasting lipid profile that includes testing for total cholesterol, low- density lipoproteins, and high-density lipoproteins. The Army pays for these examinations.

The examinations are also used to assign early-deploying reservists a physical profile rating, ranging from P1 to P4, in six assessment areas: (a) Physical capacity, (b) Upper extremities, (c) Lower extremities, (d) Hearing-ears, (e) Vision-eyes, and (f) Psychiatric. (See app. II for the Army’s Physical Profile Rating Guide.) According to the Army, P1 represents a non-duty-limiting condition, meaning that the individual is fit for duty and possesses no physical or psychiatric impairments. P2 means a condition may exist; however, it is not duty-limiting. P3 or P4 means that the individual has a duty-limiting condition in one of the six assessment areas. P4 means the individual functions below the P3 level. A rating of either P3 or P4 puts the reservist in a nondeployable status or may result in the changing of the reservist’s job classification.

Beginning in January 2003, early-deploying reservists with a permanent rating of P3 or P4 in one of the assessment areas must be evaluated by an administrative screening board—the Military Occupational Specialty/Medical Retention Board (MMRB). This evaluation determines if reservists can satisfactorily perform the physical requirements of their jobs. The MMRB recommends whether a reservist should retain a job, be reassigned, or be discharged from the military.

Army regulations that implement the statutory certification requirement provide that all reservists—including early-deploying reservists—certify their physical condition annually on a two-page certification form. Army early-deploying reservists must report doctor or dentist visits since their last examination, describe current medical or dental problems, and disclose any medications they are currently taking. (See app. III for a copy of the annual medical certificate—DA Form 7349.) In addition, the Army is required to conduct an annual medical screening for all early-deploying reservists. According to Army regulations, the Army is to meet the annual medical screening requirement by reviewing the medical certificate required of each early-deploying reservist.

In addition, Army early-deploying reservists are required to undergo, at the Army’s expense, an annual dental examination. The Army is also required to provide and pay for the dental treatment needed to bring an early- deploying reservist’s dental status up to deployment standards—either dental class 1 or 2. (See table 1 for a general description of each dental classification.)

According to Army officials, most of the 5-year and 2-year physical examinations, the dental examinations, and the dental treatments that have been performed were administered by military medical personnel. However, beginning in March 2001, the Army started outsourcing some examinations through the Federal Strategic Healthcare Alliance (FEDS_HEAL)—an alliance of private physicians and dentists and other physicians and dentists who work for the Department of Veterans Affairs and HHS’s Division of Federal Occupational Health. FEDS_HEAL is a program that allows Army early-deploying reservists to obtain required physical and dental examinations and dental treatment from local providers. The Army contracts and pays for these examinations. About 12,000 of these providers nationwide participate in FEDS_HEAL. The Army plans to increase its reliance on FEDS_HEAL to provide physical and dental examinations, and dental treatment for early-deploying reservists.

Periodic Physical and Dental Examinations Are Valuable for Assessing Health Status and Provide Beneficial Information to the Army

Medical experts recommend physical and dental examinations as an effective means of assessing health. For some people, the frequency and content of physical examinations vary according to the specific demands of their job. Because Army early-deploying reservists need to be healthy to fulfill their professional responsibilities, periodic examinations are useful for assessing whether they can perform their assigned duties. Furthermore, the estimated annual cost to conduct periodic examinations—about $140—is relatively modest compared to the thousands of dollars the Army spends for salaries and training of early- deploying reservists—an investment that may be lost if reservists can not perform their assigned duties.

Experts Look to Screenings and Examinations as Key Indicators of Health

Physical and dental examinations are geared towards assessing and improving the overall health of the general population. The U.S. Preventive Services Task Force and many other medical organizations no longer recommend annual physical examinations for adults—preferring instead a more selective approach to detecting and preventing health problems. In 1996, the task force reported that while visits with primary care clinicians are important, performing the same interventions annually on all patients is not the most clinically effective approach to disease prevention. Consistent with its finding, the task force recommended that the frequency and content of periodic health examinations should be based on the unique health risks of individual patients. Today, many health associations and organizations are recommending periodic health examinations that incorporate age-specific screenings, such as cholesterol screenings for men (beginning at age 35) and women (beginning at age 45) every 5 years, and clinical breast examinations every 3 to 5 years for women between the ages of 19 and 39. Further, oral health care experts emphasize the importance of regular 6- to 12-month dental examinations.

Both the private and public sectors have established a fixed schedule of physical examinations for certain occupations to help ensure that workers are healthy enough to meet the specific demands of their jobs. For example, the Federal Aviation Administration requires commercial pilots to undergo a physical examination once every 6 months. U.S. National Park Service personnel who perform physically demanding duties have a physical examination once every other year for those under age 40, and on an annual basis for those over age 40. Additionally, guidelines published by the National Fire Protection Association recommend that firefighters have an annual physical examination regardless of age.

In the case of Army early-deploying reservists, the goal of the physical and dental examinations is to help ensure that the reservists are fit enough to be deployed rapidly and perform their assigned jobs. Furthermore, the Army recognizes that some jobs are more demanding than others and require more frequent examinations. For example, the Army requires that aviators undergo a physical examination once a year, while marine divers and parachutists have physical examinations once every 3 years.

While governing statutes and regulations require physical examinations at specific intervals, the Army has raised concerns about the appropriate frequency for them. In a 1999 report to the Congress, the Offices of the Assistant Secretaries of Defense for Health Affairs and Reserve Affairs stated that while there were no data to support the benefits of conducting periodic physical examinations, DOD was reluctant to recommend a change to the statutory requirements. The report stated that additional research was needed to identify and develop a more cost-effective, focused health assessment tool for use in conducting physical examinations for reservists—in order to ensure the medical readiness of reserve forces. However, as of February 2003, DOD had not conducted this research.

Cost of Conducting Physical and Dental Examinations and Providing Dental Treatments

For its early-deploying reservists, the Army conducts and pays for physical and dental examinations and selected dental treatments at military treatment facilities or pays civilian physicians and dentists to provide these services. The Army could not provide us with information on the cost to provide these services at military hospitals or clinics primarily because it does not have a cost accounting system that records or generates cost data for each patient. However, the Army was able to provide us with information on the amount it pays civilian providers for these examinations under the FEDS_HEAL program.

Using FEDS_HEAL contract cost information, we estimate the average cost of the examinations to be about $140 per early-deploying reservist per year. We developed the estimate over one 5-year period by calculating the annual cost for those early-deploying reservists requiring a physical examination once every 5 years, calculating the cost for those requiring a physical examination once every 2 years, and calculating the cost for those requiring an initial dental examination and subsequent yearly dental examinations. The FEDS_HEAL cost for each physical examination for those under 40 is about $291, and for those over 40 is about $370. The Army estimates that the cost of annual dental examinations under the program to be about $80 for new patients and $40 for returning patients. The Army estimates that it would cost from $400 to $900 per reservist to bring those who need treatment from dental class 3 to dental class 2.

Benefits of Conducting Periodic Examinations

For the Army, there is likely value in conducting periodic examinations because the average cost to provide physical and dental examinations per early-deploying reservist—about $140 annually over a 5-year period—is relatively low compared to the potential benefits associated with such examinations. These examinations could help protect the Army’s investment in its early-deploying reservists by increasing the likelihood that more reservists will be deployable. This likelihood is increased when the Army uses examinations to identify early-deploying reservists who do not meet the Army’s health standards and are thus not fit for duty. The Army can then intervene by treating, reassigning, or dismissing these reservists with duty-limiting conditions—before their mobilization and before the Army needs to rely on the reservists’ skills or occupations. Furthermore, by identifying duty-limiting conditions or the risks for developing them, periodic examinations give early-deploying reservists the opportunity to seek medical care for their conditions—prior to mobilization.

Periodic examinations may provide another benefit to the Army. If the Army does not know the health condition of its early-deploying reservists, and if it expects some of them to be unfit and incapable of performing their duties, the Army may be required to maintain a larger number of reservists than it would otherwise need in order to fulfill its military and humanitarian missions. While data are not available to estimate these benefits, the benefit associated with reducing the number of reservists the Army needs to maintain for any given objective could be large enough to more than offset the cost of the examinations and treatments. The proportion of reservists whom the Army maintains but who cannot be deployed because of their health may be significant. For instance, according to a 1998 U.S. Army Medical Command study, a “significant number” of Army reservists could not be deployed for medical reasons during mobilization for the Persian Gulf War (1990-1991). Further, according to a study by the Tri-Service Center for Oral Health Studies at the Uniformed Services University of the Health Sciences, an estimated 25 percent of Army reservists who were mobilized in response to the events of September 11, 2001, were in dental class 3 and were thus undeployable. In fact, our analysis of the available current dental examinations at the seven early-deploying units showed a similar percentage of reservists—22 percent—who were in dental class 3. With each undeployable reservist, the Army loses, at least temporarily, a significant investment that is large compared to the cost of examining and treating these reservists. The annual salary for an Army early-deploying reservist in fiscal year 2001 ranged from $2,200 to $19,000. The Army spends additional amounts to train and equip each reservist and, in some cases, provides allowances for subsistence and housing. Additionally, for each reservist it mobilizes, the Army spends about $800. If it does not examine all of its early-deploying reservists, the Army risks losing its investment because it will train, support, and mobilize reservists who might not be deployed because of their health.

The Army Has Not Collected and Maintained All Required Medical and Dental Information on Early-Deploying Reservists

The Army has not consistently carried out the requirements that early- deploying reservists undergo 5- or 2-year physical examinations, and the required dental examination. In addition, the Army has not required early- deploying reservists to complete the annual medical certificate of their health condition, which provides the basis for the required annual medical screening. Accordingly, the Army does not have current health information on early-deploying reservists. Furthermore, the Army does not have the ability to maintain information from medical and dental records and annual medical certificates at the aggregate or individual level, and therefore does not know the overall health status of its early-deploying reservists.

Examinations Have Not Always Been Performed and Annual Medical Certificates Have Not Been Completed and Reviewed

We found that the Army has not consistently met the statutory requirements to provide early-deploying reservists physical examinations at 5- or 2-year intervals. At the seven Army early-deploying reserve units we visited, about 66 percent of the medical records were available for our review. Based on our review of these records, 13 percent of the reservists did not have a current 5-year physical examination on file. Further, the Army is also required to provide physical examinations every 2 years for Army early-deploying reservists over the age of 40. However, our review of the available records found that approximately 68 percent of early- deploying reservists over age 40 did not have a record of a current biennial examination.

Army early-deploying reservists are required by statute to complete an annual medical certificate of their health status, and regulations require the Army to review the form to satisfy the annual screening requirement. In performing our review of the records on hand, we found that none of the units we visited required that its reservists complete the annual medical certificate, and consequently, none of them were available for review. Furthermore, Army officials stated that reservists at most other units have not filled out the certification form and that enforcement of this requirement was poor.

The Army is also statutorily required to provide early-deploying reservists with an annual dental examination to establish whether reservists meet the dental standards for deployment. At the seven early-deploying units that we visited, we found that about 49 percent of the reservists whose records were available for review did not have a record of a current dental examination.

Army’s Automated Systems Do Not Contain Comprehensive Health Information on Early- Deploying Reservists

The Army’s two automated information systems for monitoring reservists’ health do not maintain important medical and dental information for early- deploying reservists—including information on the early-deploying reservists’ overall health status, information from the annual medical certificate form, dental classifications, and the date of dental examinations. In one system, the Regional Level Application Software, the records provide information on the dates of the 5-year physical examination and the physical profile ratings. In the other system, the Medical Occupational Database System, the records provide information on HIV status, immunizations, and DNA specimens. Neither system allows the Army to review medical and dental information for entire units at an aggregate level. The Army is aware of the information shortcomings of these systems and acknowledges that having sufficient, accurate, and current information on the health status of reservists is critical for monitoring combat readiness. According to Army officials, in 2003 the Army plans to expand the Medical Occupational Database System to provide the Army with access to current, accurate, and relevant medical and dental information at the aggregate and individual levels for all of its reservists—including early-deploying reservists. According to Army officials, this information will be readily available to the U.S. Army Reserve Command. Once available, the Army can use this information to determine which early-deploying reservists meet the Army’s health care standards and are ready for deployment.

Conclusions

Army reservists have been increasingly called upon to serve in a variety of operations, including peacekeeping missions and the current war on terrorism. Given this responsibility, periodic health examinations are important to help ensure that Army early-deploying reservists are fit for deployment and can be deployed rapidly to meet humanitarian and wartime needs. However, the Army has not fully complied with statutory requirements to assess and monitor the medical and dental status of early- deploying reservists. Consequently, the Army does not know how many of them can perform their assigned duties and are ready for deployment.

The Army will realize benefits by fully complying with the statutory requirements. The information gained from periodic physical and dental examinations, coupled with age-specific screenings and information provided by early-deploying reservists on an annual basis in their medical certificates, will assist the Army in identifying potential duty-limiting medical and dental problems within its reserve forces. This information will help ensure that early-deploying reservists are ready for their deployment duties. Given the importance of maintaining a ready force, the benefits associated with the relatively low annual cost of about $140 to conduct these examinations outweighs the thousands of dollars spent in salary and training costs that are lost when an early-deploying reservist is not fit for duty.

The Army’s planned expansion, in 2003, of an automated health care information system is critical for capturing the key medical and dental information needed to monitor the health status of early-deploying reservists. Once collected, the Army will have additional information to conduct the research suggested by DOD’s Offices of Health Affairs and Reserve Affairs to determine the most effective approach, which could include the frequency of physical examinations, for determining whether early-deploying reservists are healthy, can perform their assigned duties, and can be rapidly deployed.

Recommendations for Executive Action

To help ensure that early-deploying reservists are healthy to carry out their duties, we recommend that the Secretary of Defense direct the Secretary of the Army to comply with existing statutory requirements to ensure that the 5-year physical examinations for early-deploying reservists under 40 and the biennial physical examinations for early-deploying reservists over 40 are current and complete, all early-deploying reservists complete their annual medical certificate of health status and that the appropriate Army personnel review the certificate, and the required dental examinations and treatments for all early-deploying reservists are complete.

Agency Comments and Our Evaluation

The Department of Defense provided written comments on a draft of this report, which are found in appendix IV. DOD concurred with the report’s recommendations.

DOD raised some concerns about our evaluation. For example, DOD stated that the intermittent use of the terms “The Army,” “Reserve Component,” and “Army Reserve” would lead to a misunderstanding of the organization of Army Components. While DOD did not offer specific examples, we reviewed the draft to ensure that terms were used appropriately and did not make any changes. DOD also raised the concern that we used a very narrow subject group that may not reflect a valid representative sample and that the report findings could be incorrectly applied to the Army National Guard. As we noted in our draft report, our work was conducted at seven early deploying U.S. Army Reserve units— geographically dispersed in the states of Georgia, Maryland, and Texas— and our analysis of the information collected at these units is not projectable. Finally, DOD stated that methods for annually certifying physical conditions could also include completing the statement of physical condition that is preprinted on the Personnel Qualification Record, and that we did not consider whether such alternatives were used for certification. During our visits we reviewed the medical files at all locations, the personnel files at one location, and interviewed military personnel who were responsible for maintaining the records of early- deploying reservists at all locations. We were unable to find one annual medical certificate that was reviewed by military personnel to meet the statutory requirements. In addition, some military personnel were not aware of the requirement.

We are sending copies of this report to the Secretary of Defense, appropriate congressional committees, and other interested parties. Copies will also be made available to others on 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 any questions about this report, please contact me at (202) 512-7101. Another contact and major contributors are listed in appendix V.

Appendix I: Scope and Methodology

We reviewed statutes and Army policies and regulations governing annual medical and dental screenings, and periodic physical and dental examinations. We obtained data from the Office of the Chief, U.S. Army Reserve on the physical and dental examinations performed since 2001 on early-deploying reservists. We reviewed our past reports that addressed medical and dental examinations. We conducted site visits to seven U.S. Army Reserve Units located in Georgia, Maryland, and Texas—where we obtained and reviewed all available medical and dental records. There were 504 early-deploying reservists assigned to the seven units we visited. Medical records for 332 reservists were available for our review. Army administrators told us that the remaining files were in transit, with the reservist, or on file at another location. Our analysis of the information gathered at these units is not projectable. We did not review medical or dental records at Army National Guard units, but obtained information from the Guard on its medical policies.

To calculate an average annual cost to provide physical and dental examinations for Army early-deploying reservists, we obtained estimates from the Army’s Federal Strategic Healthcare Alliance (FEDS_HEAL) administrator on the costs of outsourcing the examinations. We calculated the annual cost for those reservists requiring a physical examination once every 5 years and those requiring a physical examination once every 2 years. In developing the annual cost estimate, we used DOD information on the number of Army reservists that are under 40 (approximately 75 percent), and those over 40 (approximately 25 percent). We also included the initial dental examination cost and subsequent yearly dental examination costs. All costs were averaged over one 5-year period. The average annual cost does not include allowances for inflation, dental treatment, or specialized laboratory fees such as those for pregnancy, phlebotomy, and tuberculosis. We also obtained estimates of the cost to perform dental treatments from the Army Office of the Surgeon General and Army Dental Command.

We obtained from DOD, HHS’s Office of Public Health and Science, the Centers for Disease Control and Prevention, medical associations, and dental associations studies and information concerning the advisability of periodic physical and dental examinations. From these organizations we also obtained published common practices and standards concerning periodic medical and dental examinations, age and risk factors, and the value and relevance of patients’ self-reporting of symptoms.

Appendix II: Army Physical Profile Rating Guide

Upper extremities Strength, range of motion, and general efficiency of upper arm, shoulder girdle, and upper back, including cervical and thoracic vertebrae.

Lower extremities Strength, range of movement, and efficiency of feet, legs, lower back, and pelvic girdle.

Hearing-ears Auditory sensitivity and organic disease of the ears.

Vision-eyes Visual acuity and organic disease of the eyes and lids.

No loss of digits or limitation of motion; no demonstrable abnormality; able to do hand-to- hand fighting.

No loss of digits or limitation of motion; no demonstrable abnormality; able to perform long marches, stand over long periods, and run.

Audiometer average level for each ear not more than 25 dB at 500, 1000, or 2000 Hz with no individual level greater than 30 dB. Not over 45 dB at 4000 Hz.

Uncorrected vision acuity 20/200 correctable to 20/20 in each eye.

Psychiatric Type, severity, and duration of the psychiatric symptoms or disorder existing at the time the profile is determined. Amount of external precipitating stress. Predispositions as determined by the basic personality makeup, intelligence, performance, and history of past psychiatric disorder impairment of functional capacity. No psychiatric pathology; may have history of transient personality disorder.

Upper extremities Slightly limited mobility of joints, muscular weakness, or other musculo- skeletal defects that do not prevent hand-to- hand fighting and do not disqualify for prolonged effort.

Lower extremities Slightly limited mobility of joints, muscular weakness, or other musculo- skeletal defects that do not prevent moderate marching, climbing, timed walking, or prolonged effort.

Vision-eyes Distant visual acuity correctable to not worse than 20/40 and 20/70, or 20/30 and 20/100, or 20/20 and 20/400.

Psychiatric May have history of recovery from an acute psychotic reaction due to external or toxic causes unrelated to alcohol or drug addiction.

Defects or impairments that require significant restriction of use.

Defects or impairments that require significant restriction of use.

Hearing-ears Audiometer average level for each ear at 500, 1000, or 2000 Hz, not more than 30 dB, with no individual level greater than 35 dB at these frequencies, and level not more than 55 dB at 4000 Hz; or audiometer level 30 dB at 500 Hz, 25 dB at 1000 and 2000 Hz, and 35 dB at 4000 Hz in better ear. (Poorer ear may be deaf.) Speech reception threshold in best ear not greater than 30 dB HL measured with or without hearing aid, or chronic ear disease.

Uncorrected distant visual acuity of any degree that is correctable to not less than 20/40 in the better eye.

Functional level below P3.

Functional level below P3.

Functional level below P3.

Functional level below P3.

Satisfactory remission from an acute psychotic or neurotic episode that permits utilization under specific conditions (assignment when outpatient psychiatric treatment is available or certain duties can be avoided). Functional level below P3.

Appendix III: Annual Medical Certificate

Appendix IV: Comments from the Department of Defense

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact

Acknowledgments

The following staff members made key contributions to this report: Aditi S. Archer, Richard J. Wade, Krister P. Friday, Helen T. Desaulniers, and Mary W. Reich.

Related GAO Products

Military Personnel: Preliminary Observations Related to Income, Benefits, and Employer Support for Reservists During Mobilizations. GAO-03-549T. Washington, D.C.: March 19, 2003.

Defense Health Care: Most Reservists Have Civilian Health Coverage but More Assistance Is Needed When TRICARE Is Used. GAO-02-829. Washington, D.C.: September 6, 2002.

Reserve Forces: DOD Actions Needed to Better Manage Relations between Reservists and Their Employers. GAO-02-608. Washington, D.C.: June 13, 2002.

Department of Defense: Implications of Financial Management Issues. GAO/T-AIMD/NSIAD-00-264. Washington, D.C.: July 20, 2000.

Reserve Forces: Cost, Funding, and Use of Army Reserve Components in Peacekeeping Operations. GAO/NSAID-98-190R. Washington, D.C.: May 15, 1998.

Defense Health Program: Future Costs Are Likely to Be Greater than Estimated. GAO/NSIAD-97-83BR. Washington, D.C.: February 21, 1997.

Wartime Medical Care: DOD Is Addressing Capability Shortfalls, but Challenges Remain. GAO/NSIAD-96-224. Washington, D.C.: September 25, 1996.

Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet Medical and Physical Fitness Standards. GAO/NSIAD-94-36. Washington, D.C.: March 23, 1994.

Operation Desert Storm: Problems With Air Force Medical Readiness. GAO/NSIAD-94-58. Washington, D.C.: December 30, 1993.

Reserve Components: Factors Related to Personnel Attrition in the Selected Reserve. GAO/NSIAD-91-135. Washington, D.C.: April 8, 1991.