Military Personnel
Top Management Attention Is Needed to Address Long-standing Problems with Determining Medical and Physical Fitness of the Reserve Force Gao ID: GAO-06-105 October 27, 2005The Department of Defense's (DOD) operations in time of war or national emergency depend on sizeable reserve force involvement and DOD expects future use of the reserve force to remain high. Operational readiness depends on healthy and fit personnel. Long-standing problems have been identified with reserve members not being in proper medical or physical condition. Drilling members in the reserve force by law are required to have a medical exam every 5 years and an annual certificate of their medical status. Also, DOD policies require an annual dental exam and an annual evaluation of physical fitness. Compliance with these routine requirements is the first step in determining who is fit for duty. Public Law 108-375 required GAO to study DOD's management of the health status of reserve members activated for Operations Enduring Freedom and Iraqi Freedom. GAO assessed DOD's (1) ability to determine reserve force compliance with routine exams, and (2) visibility over reserve members' health status after they are called to duty and the care, if any, provided to those deployed with preexisting conditions.
DOD is unable to determine the extent to which the reserve force complied with routine examinations due to lack of complete or reliable data. Although each reserve component employs a tracking system capable of monitoring compliance with medical exams, only one component has taken the necessary quality assurance steps to ensure the reliability of its data. While the Office of the Under Secretary of Defense for Personnel and Readiness has the responsibility for overseeing medical and physical fitness policy and processes, it has not established a management control framework and executed a plan to oversee compliance with routine examinations. Specifically, this office has not enforced holding all responsible levels accountable, ensuring that all requirements are being met, and that complete and reliable data are being entered into the appropriate tracking system. For example, this office has not enforced its own requirement for the services to report on the components' physical fitness status. Without complete and reliable data, DOD is not in a sound position to provide the Secretary of Defense or Congress assurances that the reserve force is medically and physically fit when called to active duty. DOD has only limited visibility over the health status of reserve members after they are called to duty and is unable to determine the extent of care provided to those members deployed with preexisting medical conditions despite the existence of various sources of medical information. The components collect various types of medical data, but vary in their ability to systematically identify, track, and report information on those with temporary and permanent conditions that may limit deployability. In addition, medical information is captured on predeployment forms for all members and entered into a DOD-wide centralized database. GAO has previously reported that the database has missing and incomplete health data, and DOD is working to correct this through its quality assurance program. GAO found during this review that DOD has continued to make progress entering the data from the forms into the database, but the data are still incomplete and the reasons why members are determined medically nondeployable are not captured in a way that is easily discernable. While the Under Secretary of Defense continues to have responsibility for overseeing the medical and physical fitness of reserve members after they are called to duty, the combatant commanders, under the Joint Chief of Staff, have this responsibility for the theater. DOD is unable to determine the care provided to those deployed with preexisting medical conditions because DOD has not determined what preexisting conditions may be allowed into a specific theater and, thus, does not know what conditions to track. Evidence GAO developed suggests that members are deployed into theater with preexisting conditions, such as diabetes, heart problems, and cancer. The impact of those who are not medically and physically fit for duty could be significant for future deployments as the pool of reserve members from which to fill requirements is dwindling and those who have deployed are not in as good health as they were before deployment.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-06-105, Military Personnel: Top Management Attention Is Needed to Address Long-standing Problems with Determining Medical and Physical Fitness of the Reserve Force
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Fitness of the Reserve Force' which was released on October 27, 2005.
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
October 2005:
Military Personnel:
Top Management Attention Is Needed to Address Long-standing Problems
with Determining Medical and Physical Fitness of the Reserve Force:
GAO-06-105:
GAO Highlights:
Highlights of GAO-06-105, a report to congressional committees:
Why GAO Did This Study:
The Department of Defense‘s (DOD) operations in time of war or national
emergency depend on sizeable reserve force involvement and DOD expects
future use of the reserve force to remain high. Operational readiness
depends on healthy and fit personnel. Long-standing problems have been
identified with reserve members not being in proper medical or physical
condition. Drilling members in the reserve force by law are required to
have a medical exam every 5 years and an annual certificate of their
medical status. Also, DOD policies require an annual dental exam and an
annual evaluation of physical fitness. Compliance with these routine
requirements is the first step in determining who is fit for duty.
Public Law 108-375 required GAO to study DOD's management of the health
status of reserve members activated for Operations Enduring Freedom and
Iraqi Freedom. GAO assessed DOD‘s (1) ability to determine reserve
force compliance with routine exams, and (2) visibility over reserve
members‘ health status after they are called to duty and the care, if
any, provided to those deployed with preexisting conditions.
What GAO Found:
DOD is unable to determine the extent to which the reserve force
complied with routine examinations due to lack of complete or reliable
data. Although each reserve component employs a tracking system capable
of monitoring compliance with medical exams, only one component has
taken the necessary quality assurance steps to ensure the reliability
of its data. While the Office of the Under Secretary of Defense for
Personnel and Readiness has the responsibility for overseeing medical
and physical fitness policy and processes, it has not established a
management control framework and executed a plan to oversee compliance
with routine examinations. Specifically, this office has not enforced
holding all responsible levels accountable, ensuring that all
requirements are being met, and that complete and reliable data are
being entered into the appropriate tracking system. For example, this
office has not enforced its own requirement for the services to report
on the components‘ physical fitness status. Without complete and
reliable data, DOD is not in a sound position to provide the Secretary
of Defense or Congress assurances that the reserve force is medically
and physically fit when called to active duty.
DOD has only limited visibility over the health status of reserve
members after they are called to duty and is unable to determine the
extent of care provided to those members deployed with preexisting
medical conditions despite the existence of various sources of medical
information. The components collect various types of medical data, but
vary in their ability to systematically identify, track, and report
information on those with temporary and permanent conditions that may
limit deployability. In addition, medical information is captured on
predeployment forms for all members and entered into a DOD-wide
centralized database. GAO has previously reported that the database has
missing and incomplete health data, and DOD is working to correct this
through its quality assurance program. GAO found during this review
that DOD has continued to make progress entering the data from the
forms into the database, but the data are still incomplete and the
reasons why members are determined medically nondeployable are not
captured in a way that is easily discernable. While the Under Secretary
of Defense continues to have responsibility for overseeing the medical
and physical fitness of reserve members after they are called to duty,
the combatant commanders, under the Joint Chief of Staff, have this
responsibility for the theater. DOD is unable to determine the care
provided to those deployed with preexisting medical conditions because
DOD has not determined what preexisting conditions may be allowed into
a specific theater and, thus, does not know what conditions to track.
Evidence GAO developed suggests that members are deployed into theater
with preexisting conditions, such as diabetes, heart problems, and
cancer. The impact of those who are not medically and physically fit
for duty could be significant for future deployments as the pool of
reserve members from which to fill requirements is dwindling and those
who have deployed are not in as good health as they were before
deployment.
What GAO Recommends:
GAO is making a number of recommendations to improve DOD‘s management
of the health status of reserve members. In commenting on a draft of
this report, DOD did not concur with two of our six recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-06-105.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Derek B. Stewart, (202)
512-5559, stewartd@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Lack of DOD Oversight Hinders DOD's Ability to Determine Reserve
Components' Compliance with Routine Medical and Physical Fitness
Examination Requirements, but Indications of Noncompliance Exist:
DOD Lacks Visibility over the Health Status of Reserve Components after
Being Called to Active Duty and the Extent to which Members with
Preexisting Conditions Required Care during Deployment:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Service Decisions Concerning Reserve Components'
Deployability, November 2001 through June 2005:
Table 2: Service Decisions Concerning Active Components' Deployability,
November 2001 through June 2005:
Table 3: Total Predeployment Referral Rate by Reserve Component,
November 2001 through June 2005:
Table 4: Total Predeployment Referral Rate by Active Component,
November 2001 through June 2005:
Table 5: Rate of Servicemembers Health Status as Recorded on Pre-and
Postdeployment Forms for Active and Reserve Components from November
2001 through June 2005:
Figures:
Figure 1: Rate of Medical Referrals by Type for Active and Reserve
Components from November 2001 through June 2005:
Figure 2: Medical Conditions of Army National Guard and Army Reserve
Members in a Medical Holdover Status as of August 11, 2005:
Abbreviations:
AFAA: Air Force Audit Agency:
AFFMS: Air Force Fitness Management System:
AMSA: Army Medical Surveillance Activity:
ANG: Air National Guard:
APFT: Army Physical Fitness Test:
CENTCOM: U.S. Central Command:
DIMHRS: Defense Integrated Military Human Resources System:
DNBI: Disease Nonbattle Injury:
DOD: Department of Defense:
GAO: Government Accountability Office:
HCP: Health Care Provider:
IMR: Individual Medical Readiness:
JMeWS: Joint Medical Work Station:
JMROC: Joint Medical Readiness Oversight Committee:
JPTA: Joint Patient Tracking Application:
MEDPROS: Medical Protection System:
MND-TM: Medical Nondeployable Tracking Module:
MODS: Medical Operational Data System:
MORDT: Mobilization Operational Readiness Deployment Test:
MRRS: Medical Readiness Reporting System:
NDAA: National Defense Authorization Act:
OSD: Office of the Secretary of Defense:
OUSD/P&R: Office of the Under Secretary of Defense for Personnel and
Readiness:
PHA: Preventive Health Assessment:
PHAM: Periodic Health Assessment Monitor:
PIMR: Preventive Health Assessment and Individual Medical Readiness:
PRIMS: Physical Readiness Information Management System:
RCPHA: Reserve Component Periodic Health Assessment:
TRAC2ES: TRANSCOM Regulating Command and Control Evacuation System:
TRANSCOM: U.S. Transportation Command:
United States Government Accountability Office:
Washington, DC 20548:
October 27, 2005:
The Honorable John Warner:
Chairman:
The Honorable Carl Levin:
Ranking Minority Member:
Committee on Armed Services:
United States Senate:
The Honorable Duncan L. Hunter:
Chairman:
The Honorable Ike Skelton:
Ranking Minority Member:
Committee on Armed Services:
House of Representatives:
The Department of Defense's (DOD) operations in time of war or national
emergency are currently dependent upon sizeable National Guard and
Reserve involvement and DOD expects future use of the reserve force to
remain high. DOD policy acknowledges the importance that reserve
component[Footnote 1] members are medically and physically fit[Footnote
2] for deployment[Footnote 3] when called to active duty. As of June
2005, more than 323,000 reserve component members had deployed in
support of Operation Enduring Freedom and Operation Iraqi
Freedom,[Footnote 4] which is almost three times the number of reserve
component members deployed in support of Operations Desert Shield and
Desert Storm. Reserve forces played a vital role in Operations Desert
Shield and Desert Storm. However, problems were revealed with reserve
component members not being in proper medical or physical condition for
these deployments. Some members could not deploy to the Persian Gulf,
and others had difficulty performing their missions while there. In an
effort to help obviate similar problems in the future, Congress passed
legislation during the 1990s to help monitor and track the health
status of deployed members of the Armed Forces, including reserve
component members.[Footnote 5]
Public Law 108-375, the Ronald W. Reagan National Defense Authorization
Act for Fiscal Year 2005, requires GAO to study DOD's management of the
health status of reserve component members ordered to active duty in
support of Operation Enduring Freedom and Operation Iraqi Freedom.
Specifically, GAO assessed: (1) DOD's ability to determine the reserve
components' compliance with routine medical and physical fitness
examinations, and (2) DOD's visibility over reserve components' health
status after they are called to duty and the care, if any, provided to
those deployed with preexisting conditions.
To address our first objective, we reviewed federal statutes and Office
of the Secretary of Defense (OSD) applicable directives and
instructions to identify and understand the roles and responsibilities
of the offices within DOD for management of the health status of the
reserve components. We discussed these statutes and guidance with
senior officials in the Office of the Under Secretary of Defense for
Personnel and Readiness. We discussed service policies for medical and
physical fitness with military officials within the service surgeon
general offices and officials responsible for physical fitness in the
service personnel and operations functions. We also analyzed reserve
component regulations and policies and discussed these with responsible
reserve component officials. We took steps to assess the reliability of
these reserve component compliance data and we discuss the results of
our assessment in the report. We also visited several unit-level
commands in all six reserve components. In addition, we conducted a
limited medical and personnel file review and group discussions at an
Army National Guard unit in the Mid-Atlantic and an Army Reserve unit
in the Mid-west for the purposes of understanding some of the issues
confronting the Army components in terms of compliance.
To address our second objective, we interviewed reserve component
headquarters officials and active component officials responsible for
mobilizing the reserve components and observed an Army mobilization of
Army National Guard and Army Reserve members at Fort Bliss, Texas to
obtain information on processes used to screen members for their
medical deployability. We obtained and analyzed data provided on
medical deployability from DOD's centralized database on pre-and
postdeployment health assessments, maintained at the Army Medical
Surveillance Activity (AMSA) and discussed available data with AMSA
officials. We also obtained and analyzed data on Army reserve component
members held at mobilization stations for medical reasons and discussed
these data with officials from the Office of the Assistant Secretary of
the Army for Manpower and Reserve Affairs and the Army Office of the
Surgeon General. Based on our review of the AMSA database we used, we
determined that the data from it were reliable for the purposes of this
report. To address the extent of medical care provided in theater for
preexisting medical conditions, we reviewed the Joint Chiefs of Staff
policy for Deployment Health Surveillance and Readiness and information
provided by the U.S. Central Command (CENTCOM) Surgeon General office
regarding medical deployment criteria for Operation Enduring Freedom
and Operation Iraqi Freedom and discussed these policies with the
appropriate DOD officials. We met with medical officials who served in
theater and discussed situations they witnessed related to reserve
members who had deployed with preexisting conditions. We conducted our
review from October 2004 through September 2005 in accordance with
generally accepted government auditing standards. A more thorough
description of our scope and methodology is provided in appendix I.
Results in Brief:
DOD is unable to determine the extent to which the reserve components
comply with routine medical and physical fitness examination
requirements due to a lack of OSD guidance and oversight, and
incomplete or unreliable compliance data supplied by the components.
Although the Office of the Under Secretary of Defense for Personnel and
Readiness (OUSD/P&R) has the responsibility for overseeing medical and
physical fitness policy and processes, this office has not established
a management control framework and executed a plan to oversee
compliance with routine examinations. For example, OUSD/P&R has not
provided guidance to the reserve components regarding requirements for
the 5-year medical examination and an annual medical certificate. Thus,
each reserve component has developed its own implementing policies with
differences in scope, frequency, and administration of the medical
examination. Lack of OSD guidance makes oversight difficult because
uniform criteria against which to measure compliance do not exist.
DOD's ability to determine the extent of compliance has been hindered
because OSD does not track reserve components' compliance with routine
medical examinations. In addition, the data reported at the reserve
component level have been incomplete and unreliable for purposes of
determining compliance with routine medical and physical fitness
examination requirements, and responsibility for compliance has not
been enforced. For example, although each reserve component employs a
tracking system capable of monitoring compliance with medical
examinations, only one reserve component--the Navy Reserve--has taken
the necessary quality assurance steps to ensure the reliability of its
data on compliance.
Further, DOD has not enforced its own requirement for the services to
report on the status of the reserve and active components' physical
fitness. No reserve component has a tracking system that can report
complete and reliable data on compliance with physical fitness
examinations on a componentwide basis. Moreover, although the reserve
components place the responsibility for tracking compliance with
medical and physical fitness examinations on the unit commander, the
reserve components do not always hold the unit commanders accountable
and the unit commanders do not always enforce the compliance of their
members. OUSD/P&R has not enforced holding all responsible levels
accountable, ensuring that all requirements are being met, and complete
and reliable data are being entered into the appropriate tracking
system. Despite DOD's inability to determine the extent of reserve
component compliance with routine medical and physical fitness
examinations, we found indications of noncompliance. For example, a
limited review of medical files at one Army National Guard and one Army
Reserve location, data from a Navy report, test results of two units in
a Marine Corps battalion, and data from a review conducted by the Air
Force Audit Agency indicate some noncompliance at all components with
routine examination requirements. OSD's lack of oversight could
negatively impact operational readiness for future deployments as the
number of needed personnel may not be medically and physically fit when
called to active duty.
DOD has limited visibility over the health status of reserve component
members after they are called to duty and is unable to determine the
extent of care provided to those members deployed with preexisting
medical conditions despite the existence of various sources of medical
information. For example, the reserve components all collect various
types of medical data, but vary in their ability to systematically
identify, track, and report information on members with both temporary
and permanent conditions that limit medical deployability. In addition,
medical information is captured on predeployment forms for all reserve
members and entered into a DOD-wide centralized database, but the data
are incomplete and the reasons why members were found nondeployable are
not captured in a way that is easily discernable. Furthermore, DOD is
unable to determine the care provided to those deployed with
preexisting medical conditions because DOD has not determined what
preexisting conditions may be allowed into a specific theater of
operations and therefore does not know what conditions to track. The
medical deployment criteria specific to Operations Iraqi Freedom and
Enduring Freedom are still evolving, and although DOD has a number of
systems for tracking medical conditions in theater, the current
databases do not capture data on known preexisting conditions.
Developing and updating specific medical criteria for a theater of
operations are the responsibilities of the combatant command. In the
absence of specific theater guidance, the services relied on their own
deployment criteria. For the Army, specific deployment medical criteria
did not exist until February 2005. Evidence we developed suggests that
reserve members did deploy with preexisting medical conditions that
could not be adequately addressed in theater, such as diabetes, heart
problems, and cancer. The impact on operations of those determined
nondeployable or those deployed with mission-limiting medical
conditions is unknown. However, the impact could be significant for
future deployments as the pool of Guard and Reserve members from which
to fill requirements is dwindling and those who have deployed are not
in as good health as they were before deployment.
We are making several recommendations in this report. For DOD to have
visibility over the reserve components' compliance with routine
examinations, we recommend that DOD establish a management control
framework and execute a plan for improving oversight and take steps to
enforce the service reporting requirement on the status of their
members' physical fitness. To improve DOD's visibility over reserve
component members' health status after they are called to duty, we
recommend that DOD oversee the development of the reserve components'
tracking systems to identify and track members' temporary and permanent
medical conditions that limit deployability and modify the
predeployment forms to better capture the reasons for nondeployment and
medical referrals. To help prevent the deployment of members with
preexisting medical conditions that could adversely affect the mission
and strain resources in theater, we recommend that DOD develop medical
criteria for specific theaters and explore using existing tracking
systems to track those with treatable preexisting medical conditions.
In written comments on a draft of this report, DOD did not concur with
our first and fourth recommendation, partially concurred with our fifth
recommendation, and concurred with our second, third and sixth
recommendations. DOD did not concur with our first recommendation that
it establish a management control framework and execute a plan for
issuing guidance, establishing quality assurance for data reliability,
and tracking compliance with routine medical examinations. DOD did not
state that it disagreed with our findings; however, DOD stated that it
had initiatives underway that addressed our recommendation. We disagree
with DOD's conclusion because, based on our review, we do not believe
that DOD's initiatives are far enough along to dismiss further action,
and we continue to believe that our recommendation has merit. DOD
concurred with our second recommendation that DOD take steps to enforce
the services' reporting requirement on the status of their members'
physical fitness. During our review none of the reports had been
submitted to the Principal Deputy as required. We raised concerns in
this report about the data reliability of the tracking systems for
physical fitness. Just as we found with routine medical examinations,
we also found that DOD lacked quality assurance of the data on
compliance with physical fitness examinations in its tracking systems.
We note that the responsible office for physical fitness oversight, the
Office of Morale, Welfare, and Recreation, does not participate on the
Joint Medical Readiness Oversight Committee that is directed to oversee
improvements in medical readiness, nor are we aware of any DOD plans to
include improvements in the oversight of physical fitness in its
comprehensive medical readiness plan. Therefore, we have expanded our
first recommendation to include routine physical fitness examinations
in the actions to be addressed.
DOD concurred with our recommendation that DOD oversee the development
of the reserve components' tracking systems to identify and track
members' temporary and permanent medical conditions that limit
deployability. DOD did not concur with our recommendation that DOD
modify the medical predeployment form to better capture reasons for
nondeployment and medical referrals. DOD stated that the best sources
of accurate information about what medical reasons kept service members
from deploying are the permanent medical records. We continue to
believe our recommendation has merit because DOD has no way to
systematically analyze the information to determine why servicemembers
are medically nondeployable. DOD partially concurred with our
recommendation that DOD determine what preexisting medical conditions
should be allowed into a specific theater of operations, especially
during the initial stages of operations, and take steps to consistently
utilize these criteria for determining medical deployability. DOD also
noted that due to the ever-changing nature of a theater of operations
and the inexact nature of medicine, a list of nondeployable preexisting
conditions will never be fully comprehensive or fully enforceable. We
agree that a list of nondeployable preexisting medical conditions can
never be fully comprehensive; however, we still believe DOD could
establish a list of what preexisting medical conditions should be
allowed into specific theaters of operations, especially during the
initial stages of operations, so that in future deployments DOD would
not experience situations such as those that occurred with members
being deployed into Iraq who clearly had preexisting conditions that
should have prevented their deployment. DOD concurred with our
recommendation that DOD explore using existing tracking systems to
track those who have treatable preexisting medical conditions in
theater. DOD noted that refinements to medical tracking system are
ongoing. We wish to note that before DOD's tracking systems can be used
to track those who have treatable preexisting medical conditions in
theater, DOD must determine what preexisting medical conditions should
be allowed into a specific theater of operations as called for in our
fifth recommendation.
Background:
As required by law,[Footnote 6] each reserve component is to make
available qualified personnel for active duty in the armed forces in
time of war or national emergency and at such other times as national
security requires. With this requirement comes the responsibility that
each reserve component provides personnel who are medically and
physically fit for active duty. As noted in DOD guidance,[Footnote 7]
fitness specifically includes the ability to accomplish the task and
duties unique to a particular operation, and ability to tolerate the
environmental and operational conditions of the deployed location,
including wear of protective equipment.
Reserve Components and Routine Medical and Physical Fitness
Examinations:
DOD reserve components include the Army Reserve, the Army National
Guard, the Air Force Reserve, the Air National Guard, the Navy Reserve,
and the Marine Corps Reserve. Reserve forces consist of three
categories: the Ready Reserve, the Standby Reserve, and the Retired
Reserve. The Ready Reserve had approximately 1.1 million National Guard
and Reserve members at the end of fiscal year 2004, and its members
were the only reservists who were subject to involuntary mobilization
under the partial mobilization authorized by President Bush following
the attacks of September 11, 2001. Within the Ready Reserve, there are
three subcategories: the Selected Reserve, the Individual Ready
Reserve, and the Inactive National Guard. Members of all three
subcategories are subject to a mobilization under a partial
mobilization but routine medical and physical fitness policies apply
primarily to the Selected Reserve, consisting of about 850,000 members
at the end of fiscal year 2004.[Footnote 8]
DOD administers medical examinations to military personnel for various
reasons at different intervals. These include examinations at
accession, mobilization,[Footnote 9] for special duty assignments, and
at separation and retirement. The examinations that are required
routinely for Selected Reserve members to ensure ongoing medical and
physical fitness include two that are prescribed by federal statute and
the second two prescribed by DOD regulations and policy. Compliance
with these routine requirements is the first step toward determining
who is fit for duty.
Federal statute[Footnote 10] prescribes that each member of the
Selected Reserve[Footnote 11] who is not on active duty is required to:
* be examined as to the member's physical (medical) fitness every 5
years, or more often as the respective Secretary considers necessary;
and:
* complete an annual certificate of medical condition.
DOD policy prescribes that each member of the Selected Reserve:
* receive an annual dental examination; and:
* be evaluated annually for physical fitness for duty, to include an
assessment of aerobic capacity, muscular strength, muscular endurance,
and desirable fat composition.
Reserve Components Differ in Approaches to Mobilize and Medically
Screen Members for Deployment:
Within the constraints of the existing mobilization
authorities[Footnote 12] and DOD guidance, the services have
flexibility as to how, where, and when they conduct mobilization
processing. As a result, the services differ in how they mobilize and
consequently medically screen members upon notification that a unit or
individual will be called to active duty. The Army and Navy use
centralized approaches, mobilizing their reserve component forces at a
limited number of locations. The Army uses 15 primary sites that it
labels "power projection platforms" and 12 secondary sites called
"power support platforms." The Navy has 15 geographically dispersed
Navy Mobilization Processing Sites but is currently using only 5 of
these sites because of the relatively small numbers of personnel who
are mobilizing.
By contrast, the Air Force uses a decentralized approach, mobilizing
its reserve component members at their home stations--135 for the Air
Force Reserve and 90 for the Air National Guard--where all medical
screening is performed. The Marine Corps uses a hybrid approach. It has
five Mobilization Processing Centers to centrally mobilize individual
reservists and is currently using three of these centers. However, the
Marine Corps uses a decentralized approach to mobilize its units.
Selected Marine Corps Reserve units do most of their mobilization
processing at their home stations, including medical screening, and
then report to their gaining commands.
Roles and Responsibilities for Developing and Implementing Examination
Requirements:
Within the Office of the Under Secretary of Defense for Personnel and
Readiness, the Office of the Assistant Secretary of Health Affairs is
responsible for developing medical policies and processes; the
Principle Deputy to the Under Secretary oversees the Office of Morale,
Welfare, and Recreation for developing physical fitness policies; and
the Office of the Assistant Secretary for Reserve Affairs serves in an
advisory capacity to the Under Secretary to determine how the reserve
components can better implement these requirements. Each service's
Assistant Secretary for Manpower and Reserve Affairs provides force
management policy for both the active and reserve components. It is
then the responsibility of each National Guard and Reserve Command--the
Chief, Army Reserve, the Director of the Army National Guard, the Chief
of the Navy Reserve (Commander of Navy Reserve Forces and Commander of
Marine Corps Reserve Forces), Chief of the Air Force Reserve, and the
Director of the Air National Guard--that the policies for medical and
physical fitness examinations are properly implemented for their
respective commands. Each National Guard and Reserve unit commander is
responsible for ensuring that the members under his or her command are
provided routine medical and physical examinations in a timely manner,
and for identifying and processing members who are not medically
qualified or physically fit for active duty. The reserve component
member is responsible for meeting scheduled medical examination
requirements, obtaining any recommended follow-up medical and dental
care from his or her personal (civilian) medical provider, and
truthfully reporting any changes in his or her medical or dental
condition to military unit commanders and military medical personnel.
Upon mobilization, responsibility for the medical and physical fitness
of the reserve component members transfers to the active duty
counterparts.
Problems Identified with Medical Deployability during Operations Desert
Shield and Desert Storm:
Several studies identified medical issues with the reserve component
members called to duty for Operations Desert Storm and Desert Shield. A
1991 Army Inspector General report[Footnote 13] estimated that as many
as 8,000 reserve component personnel were found to be medically
nondeployable upon arrival at mobilization stations. Even though all
but 1,100 eventually deployed, the nondeployable soldiers disrupted the
mobilization process because units had to undergo extensive efforts to
replace nondeployable reserve members with those who could be deployed.
The report also noted that some soldiers who had coronary bypass
surgery, cancer, and amputations had not been identified at their home
stations and reported to their mobilization station. In 1991, we
reported[Footnote 14] that medical screenings conducted at mobilization
stations identified numerous problems that impaired soldiers' ability
to deploy, including ulcers, chronic asthma, spinal arthritis,
hepatitis, seizures, and diabetes. In 1992, we reported[Footnote 15]
that because many medical personnel were found nondeployable for
various reasons, including medical reasons, many units deployed with
medical personnel shortages and were not fully mission capable upon
arrival in the Persian Gulf. For example, two reserve component
surgeons--one who was unable to stand for more than 30 minutes and
another who had Parkinson's disease--reported for duty but were unable
to deploy due to their conditions. A 1992 Sixth U.S. Army Inspector
General report[Footnote 16] stated that many soldiers deployed to
Southwest Asia had to return to the United States because of medical
conditions that had not been previously diagnosed. This report noted
that home unit commanders were not identifying soldiers with severe
medical problems, some permanent, to determine if they were medically
fit to perform their duties and job assignments before deploying.
In 1994,[Footnote 17] we did a comprehensive review of the medical and
physical fitness policies for reserve component members serving in
Operations Desert Storm and Desert Shield and found that at one Army
mobilization station nearly 4 percent of the reserve component members
reporting for duty had serious medical conditions including cancer and
heart disease. One soldier had double kidney failure, one had muscular
dystrophy, and another had a gunshot wound to the head. We found that
DOD medical policy, which permits the services to retain nondeployable
reservists, was inconsistent with a military strategy that requires
forces to be capable of responding quickly to unexpected military
contingencies anywhere in the world and we recommended that DOD revise
its policy that allows members not to be worldwide deployable, but DOD
disagreed and did not take action. We also found that DOD was not aware
of the physical fitness problems because the services were not
reporting fitness information as DOD required and GAO recommended that
DOD revise its directive to require services to report on their
members' physical fitness status. DOD concurred with our
recommendations and agreed to take actions. Other related GAO products
are found at the end of this report.
DOD's System to Assess Active and Reserve Component Members' Health
Status Prior to Deployments:
Section 1074f of Title 10, United States Code requires that the
Secretary of Defense establish a system to assess the medical condition
of members of the armed forces (including members of the reserve
components) who are deployed outside of the United States or its
territories or possessions as part of a contingency operation or combat
operation. It further requires that records be maintained in a
centralized location to improve future access to records, and that the
secretary establish a quality assurance program to evaluate the success
of the system in ensuring that members receive pre-and postdeployment
medical examinations and that record-keeping requirements are met.
DOD policy requires that the services collect pre-and postdeployment
health information from their members, and submit copies of the forms
that are used to collect this information to the Army Medical
Surveillance Activity (AMSA).[Footnote 18] Initially, deployment health
assessments were required for all active and reserve component
personnel who were on troop movements resulting from deployment orders
of 30 continuous days or greater to land-based locations outside the
United States that did not have permanent U.S. military treatment
facilities. However, on October 25, 2001, the Assistant Secretary of
Defense for Health Affairs updated DOD's policy and required deployment-
related health assessments for all reserve component personnel called
to active duty for 30 days or more. The policy specifically stated that
the assessments were to be done "whether or not the personnel were
deploying outside the United States." Both assessments use a
questionnaire designed to help military healthcare providers in
identifying health problems and providing needed medical care. The
predeployment health assessment is generally administered at the
service mobilization site or unit home station before deployment.
On February 1, 2002, the Chairman of the Joint Chiefs of Staff issued
updated deployment health surveillance procedures. Among other things,
these procedures specified that active and reserve component personnel
must complete or revalidate the health assessment within 30 days prior
to deployment. The procedures also stated that the original completed
health assessment forms were to be placed in the military member's
permanent medical record and a copy "immediately forwarded to AMSA."
Both forms include demographic information about the servicemember,
member-provided information about the member's general health, and
information about referrals that are issued when service medical
providers review the health assessments. The predeployment assessment
also includes a final medical disposition that shows whether the member
was deployable or not.
In September 2003,[Footnote 19] we reported that DOD did not maintain a
complete, centralized database of the active Army and Air Force
components' member health assessments and immunizations. Following our
2003 review, DOD established a deployment health quality assurance
program to improve data collection and accuracy. The department's first
annual report documenting issues relating to deployment health
assessments was issued in May 2005.
In September 2004,[Footnote 20] we reported similar findings for the
reserve component members. We reported that DOD's ability to
effectively manage the health status of its reserve component members
is limited because its centralized database has missing and incomplete
health records and it has not maintained full visibility over reserve
component members with medical problems. For example, the Marine Corps
did not send predeployment health assessments to DOD's database as
required, due to unclear guidance and a lack of compliance monitoring.
The Air Force has visibility of involuntarily mobilized members with
health problems, but lacks visibility of members with health problems
who are on voluntary orders. As a result, some Air Force reserve
component personnel had medical problems that had not been resolved for
up to 18 months, but the full extent of this problem was unknown since
the Air Force did not have a mechanism for tracking members who are on
voluntary duty orders with medical problems. We made several
recommendations regarding improvements in this area and DOD generally
concurred with our recommendations and agreed to take actions.
Recent DOD Efforts in Response to the 2005 National Defense
Authorization Act:
Section 731 of the Ronald W. Reagan National Defense Authorization Act
for Fiscal Year 2005 (NDAA) requires the Secretary of Defense to
develop and implement a comprehensive plan to improve medical readiness
of members of the Armed Services by focusing on areas such as health
status, health surveillance, and accountability for medical readiness.
The mandate also required that the Secretary of Defense establish a
Joint Medical Readiness Oversight Committee (JMROC) with a specified
membership to oversee the development and implementation of a
comprehensive medical readiness plan.[Footnote 21]
In response to the act, the first meeting of the JMROC was held in
February 2005 during this review. The committee is chaired by the Under
Secretary of Defense for Personnel and Readiness and membership
includes the Assistant Secretaries of Defense for Reserve Affairs and
Health Affairs, the Joint Staff Surgeon, the Chief of the National
Guard Bureau, Army Reserve, Navy Reserve, Air Force Reserve and the
Commander of the Marine Corps Reserve, as well as the Vice Chiefs of
Staff of the Army, Vice Chief of Navy Operations, the Vice Chief of
Staff of the Air Force and the Assistant Commandant of the Marine Corps
as well as their respective Surgeon Generals and Assistant Secretaries
for Manpower and Reserve Affairs, and a representative of the
Department of Veterans Affairs.
A draft copy of the Comprehensive Medical Readiness Plan which
addresses all defense medical issues identified in the act was signed
by the Under Secretary of Defense for Personnel and Readiness on June
23, 2005. Officials from the Force Health Protection Directorate in the
OSD Office of Health Affairs--which is providing the staff for drafting
and overseeing this effort--stated that financial and legislative
constraints, which may limit the implementation of the plan, will have
to be identified and addressed, and indicators for measuring progress
will have to be developed before the plan is finalized.
Among other things, the draft plan specifies that DOD:
(l) institutionalize the Individual Medical Readiness[Footnote 22]
(IMR) reporting process by developing a DOD instruction for the IMR and
requires that this information be provided to commanders to assist them
in improving the health status of members of their units;
(2) expand and improve the pre-and postdeployment assessment process by
refining the predeployment survey to improve consistency with the
postdeployment survey and develop periodic postdeployment health
reassessments;
(3) develop a policy defining the circumstances under which treatment
for medical conditions may be provided in theater and circumstances
under which medical conditions are to be resolved prior to deployment;
and:
(4) review the results of this GAO study.
Lack of DOD Oversight Hinders DOD's Ability to Determine Reserve
Components' Compliance with Routine Medical and Physical Fitness
Examination Requirements, but Indications of Noncompliance Exist:
DOD is unable to determine the extent to which the reserve components
are in compliance with routine medical and physical fitness examination
requirements primarily due to a lack of OSD guidance, oversight, and
incomplete or unreliable compliance data supplied by the components.
Although the Office of the Under Secretary of Defense for Personnel and
Readiness (OSD/P&R) has the responsibility for overseeing medical and
physical fitness policy and processes, this office has not established
a management control framework and executed a plan to oversee
compliance with routine examinations. For example, OSD/P&R has not
provided guidance to the reserve components regarding requirements for
the 5-year medical examination and an annual medical certificate. Thus,
in the absence of OSD guidance, each reserve component has developed
its own implementing policies, resulting in differences in scope,
frequency, and administration making it difficult because uniform
criteria against which to measure compliance do not exist; however, OSD
has provided consistent guidance for dental and physical fitness
examinations. DOD's ability to determine the extent of compliance has
been hindered because OSD does not oversee reserve component members'
compliance with the routine physical fitness or medical examination
requirements. Furthermore, the data reported at the reserve component
level have been incomplete and unreliable for purposes of determining
compliance with routine medical and physical fitness examinations, and
responsibility for compliance has not been enforced. We found
indications of noncompliance during our site visits and reviews of
existing audit reports and investigations. OSD's lack of oversight
could negatively impact operational readiness for future deployments,
as the number of needed personnel may not be medically and physically
fit for active duty.
Lack of OSD Guidance Contributes to Variations in Examination Policies
among the Components:
Although OSD/P&R has the responsibility for overseeing medical and
physical fitness policy and processes, this office has not established
a management control framework and executed a plan that includes
issuing guidance to the reserve components on compliance with the
requirements for the 5-year medical examination and an annual medical
certificate. For example, the statutory requirement for the 5-year
medical examination has not been defined by OSD, leaving each reserve
component to develop implementing guidance, resulting in differences in
scope, frequency, and administration of the examination among the
components. In addition, there has not been any OSD implementing
guidance regarding the statutory requirement for an annual medical
certificate, and so different guidance has been developed by the
surgeons' general offices responsible for each of the six reserve
components. Lack of OSD guidance makes oversight difficult to determine
because the uniform criteria against which to measure the components'
compliance do not exist. OSD, through the Office of the Assistant
Secretary of Defense for Health Affairs, has established a consistent
requirement and implementation policy for an annual dental examination.
OSD has also established a consistent requirement for a physical
fitness examination, although the specific content of the physical
fitness examination varies among the components and it is not
coordinated with the medical examinations.
5-Year Medical Examination Requirements Vary among the Components:
The requirement for a routine medical examination has been in effect
for all active and reserve components since at least 1960.[Footnote 23]
Yet, as of September 2005, OSD has not developed a plan or provided
direction to the components on how to implement this
requirement.[Footnote 24] In the absence of OSD guidance, the surgeons
general responsible for the four services and six reserve components
have each developed their own separate implementing guidance for the
current requirement[Footnote 25] for a 5-year medical examination,
resulting in differences in scope, frequency, and administration among
the components as illustrated below.
Routine medical examinations include assessments in six areas: physical
capacity or stamina, upper extremities, hearing and ears, lower
extremities, eyes/vision, and psychiatric.[Footnote 26] For Army active
and reserve component members older than age 40, there are additional
age-specific screenings such as prostate examination, a prostate-
specific antigen test, and a fasting lipid profile that includes
testing for total cholesterol, low-density lipoproteins, and high-
density lipoproteins. The Department of the Navy conducts routine
medical examinations on all Navy and Marine Corps active component and
reserve members that include height and weight measurements, blood
pressure testing, urinalysis, serology, and mental issues. Those being
examined are also questioned about their past and present medical
history, including serious illnesses, injuries, chronic conditions, and
operations. The Air Force reserve components' medical examination for
nonflyers has been significantly reduced to minimize lost training time
due to annual medical requirements. The scope of the current testing
exam requirement is essentially limited to brief skin exams for scars
and cancer and limited laboratory blood work, and excludes EKGs,
cholesterol, lipid panels, depth perception, glaucoma, and mammograms.
One question asked on the questionnaire addresses mental status and
whether the member has a history of anxiety or depression.
In addition to the differing scope, the different implementing guidance
across the services has resulted in variations among the services in
the frequency and administration of the 5-year medical examinations.
For example, Army guidelines require that Selected Reserve members
complete a medical examination once every 5 years. During our review,
the Navy and Marine Corps personnel were examined at slightly different
intervals: every 5 years through age 50, every 2 years through age 60,
and annually after age 60. The Air Force is even more different, in
that it no longer requires a traditional medical examination physical
be completed every 5 years for nonflyers.[Footnote 27] Instead, members
are required to complete an annual Preventive Health Assessment (PHA),
the answers to which--combined with the member's age, gender, health
risk factors, medical history, and occupations--will determine the
types of screening and laboratory tests required and if the member
needs to be seen by a military health care provider. At a minimum,
however, Air Force reserve component members are required to have a
visit with a military health care provider, or Periodic Health
Assessment Monitor (PHAM),[Footnote 28] at least once every 3 years,
while Air National Guard members are required to visit a Health Care
Provider (HCP)[Footnote 29] at least once every 5 years. Thus,
differences exist between the two Air Force reserve components.
Annual Certification of Members Medical Condition Varies among
Components:
In the absence of any implementing guidance from OSD, guidance for the
annual certification of medical condition has been developed by the
surgeon general's offices responsible for each of the six reserve
components. Like the 5-year medical examination, the annual certificate
of medical condition is prescribed by statute[Footnote 30] which states
that "each member of the Selected Reserve who is not on active duty
shall execute and submit annually to the Secretary concerned a
certificate of physical condition." This requirement has been in law
since at least 1960 and is especially important for the reserve
components, since they are not seen by military health care providers
as often as the active duty.
The different guidance from each of the services has resulted in
differing definitions from each service as to what is involved in the
annual medical certificate. For example, Department of Army regulations
require that all members of the Army Reserve and Army National Guard
certify their medical condition annually on a two-page certification
form, where members report physician and dentist visits since their
last examination, describe current medical or dental problems, and
disclose any medications they are currently taking. Navy and Marine
Corps Selected Reserve members complete an Annual Certificate of
Physical Condition that provides information including the location of
their health and dental records, the dates and purpose or type of their
last complete physical and dental examinations, and the date of their
last HIV blood test among others. Reservists are also expected to
disclose any injury, illness, or disease that occurred within the last
12 months and resulted in hospitalization, or caused them to be absent
from work, school, or duty for more than 3 consecutive days; if they
have been under a physician's care or taken prescription medications
during the past 12 months; and any physical defects, family issues, or
mental problems that would prevent them from being mobilized. The Air
Force has combined this annual requirement into its PHA screening
process. Within the Air Force Reserve, the PHA process involves all
members initially completing a Reserve Component Health Risk
Assessment, which was formerly known as the Annual Medical Certificate.
In the Air National Guard, the PHA involves all the members initially
completing an annual Health History Questions/Interval History, which
was formerly known as the Annual Medical Certificate.
Dental Examination Requirements Are Consistent among Components:
The annual dental examination is a consistent requirement across the
reserve components that was established by DOD policy and provided
consistent standards for active duty and Selected Reserve members to
improve dental readiness.[Footnote 31] In 1998, the Office of the
Assistant Secretary of Defense for Health Affairs, under the Under
Secretary of Defense for Personnel and Readiness, directed that all
active duty and Selected Reserve members obtain an annual dental
examination so that DOD would have a clear picture of members' dental
readiness and fitness for duty.[Footnote 32] Although the 1998
directive required all services to provide implementation plans for
completing all dental examinations by 2001, Health Affairs recognized
that the services were having difficulty identifying both the
mechanisms for compliance and the tracking system for documentation,
and extended the goal of 90 percent compliance until February 2004. A
year and half later, DOD still does not have complete and reliable
information on all reserve components' compliance.
According to Army regulation, all soldiers within the Army National
Guard are required to have a dental examination on an annual
basis.[Footnote 33] The current annual dental examination requires an
assessment of the current state of oral health; risk for future dental
disease, including periodontal assessment; and oral cancer screening.
Prior to early 2004, the Army reserve components were still conducting
only a dental screening.[Footnote 34] In March 2000, the Navy issued
instructions requiring Navy and Marine Corps reservists to undergo an
annual dental examination. Currently, both the Air Force Reserve and
Air National Guard require annual dental examinations in line with
DOD's requirement. The Air Force Reserve made this a requirement in
January 2003, but the Air National Guard did not make it a requirement
until September 2004. Prior to these times, the required dental exam
interval was once every 3 years for the Air Force Reserve and once
every 5 years for the Air National Guard.
Physical Fitness Examination Requirements Consistent among the
Components, but Content Varies and It Is Not Coordinated with Medical
Examination Requirements:
Although the specific content of the physical fitness examination
varies among the components, the requirement for at least an annual
physical fitness examination is consistent across the components
because it was established by DOD policy which is to be monitored by
the Principal Deputy Under Secretary of Defense for Personnel and
Readiness, Office of Morale, Welfare, and Recreation.[Footnote 35]
Specifically, the policy requires that all military services and
reserve components develop and use physical fitness tests that evaluate
aerobic capacity (e.g., a timed run), muscular strength, and muscular
endurance (e.g., push-ups, pull-ups, sit-ups), and that all service
members be formally evaluated and tested for the record at least
annually (unless they are under a medical waiver).
The specific content of the physical fitness examination varies among
the components because different physical abilities are needed to meet
the services' different missions. The Army Physical Fitness Test (APFT)
is a performance test that indicates a member's ability to perform
physically and handle his or her own body weight. The APFT is required
annually for the Army National Guard. As of October 2004, the Chief of
the Army Reserve required Army reservists to be tested twice a year, as
are their active component counterparts. The APFT consists of 2 minutes
of push-ups, 2 minutes of sit-ups, and a 2-mile run (the same test is
administered to both the active and reserve component). The number of
push-ups and sit-ups and the 2-mile run time are based on the soldier's
age range and sex (the physical fitness test required to enter the Army
has the same requirements for all ages, but different requirements for
gender). All Navy personnel, regardless of age and component (active or
reserve), are required to participate semiannually in a Physical
Fitness Assessment that includes a Body Composition Assessment and
Physical Readiness Test unless medically prohibited from doing so. Body
composition is assessed by an initial weight and height screening or an
approved circumference technique to estimate body fat percentage.
Testing includes a series of physical events designed to evaluate an
individual's flexibility through a sit-reach activity, muscular
strength and endurance through curl-ups and push-ups, and aerobic
capacity through a 1.5-mile run/walk, or 500-yard or 450-meter swim.
Individuals who fail either the Body Composition Assessment or the
Physical Readiness Test or both are considered to have failed the
entire assessment. The Marine Corps has also developed a Body
Composition Program and Physical Fitness Test to assess each Marine's
fitness level. Active component Marines are tested semiannually while
Marine Corps Reservists are tested annually. Body composition standards
are health-and performance-based limits for body weight and body fat.
Physical fitness testing includes pull-ups for males, flexed-arm hang
for females, a timed abdominal crunch event, and a timed 3-mile run.
These events are designed to test the strength and stamina of the upper
body, midsection, and lower body, as well as the cardiovascular system.
The Air Force fitness program requires an annual physical assessment to
motivate all members to participate in a year-round physical
conditioning program, including proper aerobic conditioning,
strength/flexibility training, and healthy eating. Fitness assessment
results are based on a composite score calculated from results of an
aerobic assessment (1.5-mile run), muscular fitness assessment (push-
ups and crunches), and body composition measurement (abdominal
circumference measurement).
Although DOD has directed the military physical fitness programs to
complement the health promotion program within OSD's Office of Health
Affairs and senior medical officials have told us that medical and
physical fitness go "hand-in-hand," physical fitness policies are not
coordinated with medical fitness policies at the OSD, service, reserve
component, or unit levels. Furthermore, DOD did not consider physical
fitness a factor for determining the medical deployability of reserve
component members prior to deployment to Iraq and Afghanistan, even
though we reported in 1994[Footnote 36] that several Army reports on
Operations Desert Shield and Desert Storm noted fitness-related
problems that hindered wartime operations. For example, one report
noted that poor fitness contributed to the deaths by heart attack of
eight reserve component personnel deployed to the Persian Gulf.
OSD Does Not Oversee Compliance with Routine Medical and Physical
Fitness Examinations:
OSD does not have a plan to oversee reserve components' compliance with
the routine medical or physical fitness examinations, which hinders
DOD's ability to determine the extent of compliance. For example, OSD
does not track reserve component members' compliance with routine
medical examinations. In addition, OSD does not enforce its own
directive requiring the services to report on their members' compliance
with physical fitness examinations.
OSD Does Not Track Compliance with Routine Medical Examinations:
Although OSD's Office of Health Affairs has begun to track medical
readiness indicators, it does not have a plan to track compliance with
routine medical examinations and does not attempt to track compliance
with physical fitness examinations. OSD's Office of Health Affairs has
initiated a process requiring that all reserve components report
quarterly the percentage of their members who are in compliance with
the following six indicators of medical readiness: dental class I or
II; immunizations; medical readiness laboratory tests, such as
providing a blood sample; no deployment-limiting conditions; periodic
health assessment; and medical equipment, such as eyeglass inserts for
face masks. This process continues to evolve as the Office of Health
Affairs wrestles with inconsistencies in requirements among the reserve
components, especially in regard to the periodic health assessment
since each reserve component implements the requirement for a periodic
5-year medical examination differently.[Footnote 37] Without
centralized oversight and management for tracking compliance, DOD's
ability to determine the extent of compliance with routine medical
examinations may be impeded.
OSD Has Not Enforced Its Directive Requiring the Services to Report on
Compliance with Physical Fitness Exams:
OSD has not enforced its own directive requiring the reserve and active
components to report on their members' compliance with physical fitness
examinations by March 2005. Although DOD policy states that physical
fitness is a vital element of combat readiness and is essential to the
general health and well-being of military personnel, OSD and the
reserve components have been lax in reporting compliance with physical
fitness examination requirements and do not fully utilize available
systems that could report physical fitness status on a servicewide
basis. DOD established a reporting requirement for physical fitness in
November 2002, in response to recommendations from our prior reports;
however, it has not enforced compliance with this new requirement.
The new physical fitness policy requires that each military service
establish and maintain a data repository that provides baseline
statistics and a tracking mechanism that monitors physical fitness and
body fat for both the active and reserve components. The policy was
developed over the course of many years. In response to a
recommendation in our 1994 report,[Footnote 38] the Under Secretary of
Defense for Personnel and Readiness stated that revised DOD
guidance[Footnote 39] would "require the services to provide an annual
report assessing their physical fitness and health promotion programs,
to include a brief summary on how physically fit and healthy they view
their military members, both active and reserve components." Not only
did the original directive fail to require the services to submit an
annual report on the status of servicemembers' physical fitness, but
senior military officials in the office responsible for developing
these directives told us that no service ever submitted a status report
on their physical fitness programs as required by the revised
directive. In 1998, we again reported that DOD's oversight of the
physical fitness program was inadequate and that DOD had not enforced
the annual reporting requirement.[Footnote 40] Officials in the Office
of Morale, Welfare, and Recreation stated that in response to our
report, DOD guidance was again revised in November 2002, to require the
services to report annually to the Principal Deputy Under Secretary of
Defense for Personnel and Readiness[Footnote 41] on a number of very
specific physical fitness statistics, including the number of personnel
tested, the number of personnel who failed the test, and the number
placed in remedial training programs. The first report was due to the
Principal Deputy Under Secretary of Defense for Personnel and Readiness
by the military services by March 31, 2005. However, during our review
we were told by officials in the Office of Morale, Welfare, and
Recreation that none of the reports had been submitted to the Principal
Deputy as required. The Air Force, Navy, and Marine Corps were
developing their information during this review. The Army had until
March 2007 to report because, according to a signed memorandum by the
Principal Deputy Under Secretary of Defense for Personnel and
Readiness, the Army is taking steps to report this information as part
of the Defense Integrated Military Human Resources System (DIMHRS).
Until this reporting requirement is enforced, DOD's ability to
determine compliance with the physical fitness examinations may
continue to be hindered.
Reporting of Compliance at Reserve Component Level Is Hindered by
Incomplete and Unreliable Data and Lack of Enforcement:
Incomplete and unreliable data at the reserve component level regarding
compliance with routine medical and physical fitness examinations have
hindered DOD's ability to determine the extent of the reserve
components' compliance with the examination requirements. Each reserve
component employs a tracking system capable of monitoring compliance
with medical examinations, but only one reserve component--the Navy
Reserve--has data that are reliable for determining compliance with
routine medical examinations. Furthermore, even though DOD policy calls
for each military service to establish and maintain a physical fitness
data repository, no reserve component has demonstrated that its
tracking system can report complete and reliable compliance data on
physical fitness. Although the reserve components place the
responsibility for tracking compliance with medical and physical
fitness examinations on the unit commander, the reserve components do
not always hold the unit commanders accountable and the unit commanders
do not always enforce the compliance of their members. No centralized
oversight exists to hold all levels accountable, thus ensuring that all
requirements are being met.
Most Reserve Component Data on Compliance with Routine Medical
Examinations Are Unreliable:
All of the reserve components are now employing systems that can track
compliance with medical examinations, but only one reserve component--
the Navy Reserve--has taken the necessary quality assurance steps to
ensure the reliability of its data on compliance with routine medical
examinations. In contrast, we found that the data captured by the
systems used by the Army and the Air Force were unreliable for
determining compliance with routine medical examinations. We did not
assess the reliability of the data used by the Marine Corps because it
is in the process of implementing and testing the use of the Navy's
system.
Assessing data for their reliability includes quality assurance steps
to consider the completeness and currency of the data, i.e.,
determining whether there are assurances that all members are included
and the information is up to date; quality control measures, such as
conducting periodic testing of the data against medical records, to
ensure the accuracy and reliability of the data; and examining who is
using the data and for what purposes, and how reliable the user thinks
the data are. We found that the Navy Reserve had taken such quality
assurance steps. For example, the Navy has directed its Readiness
Commands to conduct routine inspections to verify medical data accuracy
in the Navy Reserve's Medical Readiness Reporting System (MRRS) and
required reserve units to review 10 percent of their medical records
for accuracy after each drill weekend. In addition, Navy Reserve units
are also required to keep the Commander, Navy Reserve Forces Command
informed about medical and dental compliance on a biweekly basis.
In contrast, we found that the compliance data on routine medical
examinations captured by the Army Medical Protection System (MEDPROS)
were unreliable for the purposes of determining compliance with routine
medical examinations. MEDPROS was developed in 1998 to track anthrax
compliance and has since matured to meet current mobilization
requirements. All Army components--active, reserve, and guard--are
required to enter members' medical compliance data into MEDPROS. We
found the data captured by this system are unreliable for monitoring
compliance with routine requirements for several reasons, including
missing data, failure to include data for all Army units, and lack of
quality assurance assessments on data content being performed to test
the data's reliability. Until quality control measures are instituted,
the Army will not be able to reliably use MEDPROS to track compliance
with the requirements for the 5-year medical examination, the annual
medical certificate, and the annual dental examination.
We also found that the Air National Guard's Preventive Health
Assessment and Individual Medical Readiness (PIMR) system and the Air
Force Reserve's Reserve Component Periodic Health Assessment (RCPHA)
system were unreliable for the purposes of determining compliance with
routine medical examinations. We found that neither system produces
data that are reliable for the purposes of determining compliance with
routine medical examinations because: (1) both the Air Force Audit
Agency and Air Force Inspection Agency have reported discrepancies in
their review of medical records and the data from these systems, and
(2) there is a high reliance on unit commands to test and verify the
reliability of the data. In addition, during our site reviews, we found
medical staff at several commands having difficulty entering large
backlogs of medical data, which raised concerns about the timeliness of
the data. Often, this backlog took several weeks to resolve and
required the assistance of full-time reservists. However, according to
program managers and database administrators, the quality of the data,
in terms of their completeness and accuracy, ranges from quite good to
exceptional when subjected to internal system software checks. Until
resources necessary to input and verify the data in a timely manner are
provided, the Air Force will not be able to rely on PIMR and RCHPA data
to determine compliance with routine medical examination requirements.
We did not assess the reliability of the data used by the Marine Corps
because it is in the process of implementing and testing the use of
Navy's system. According to a Marine Corps official, once the new
system is fully implemented, the Marine Corps will have the same
oversight capability over medical compliance that the Navy Reserve
currently has.
Reserve Components Are Unable to Report Complete and Reliable Data on
Compliance with Routine Physical Fitness Examinations on a
Componentwide Basis:
Even though DOD policy calls for each military service to establish and
maintain a physical fitness data repository, no reserve component has a
tracking system that can report complete and reliable data on
compliance with physical fitness examinations on a componentwide basis.
In fact, the Army Reserve, the Army National Guard, and the Marine
Corps Reserve do not have systems that are designed to track compliance
with physical fitness examinations on a componentwide basis.
The Navy Reserve, the Air National Guard, and Air Force Reserve each
have systems that can track compliance with physical fitness
examinations on a componentwide basis. The Navy Reserve system,
however, may not be producing reliable data at this time. Further, we
have concerns regarding the reliability of the data produced by the Air
National Guard and the Air Force Reserve because such data are not
reviewed or validated on a regular basis.
The Army does not report physical fitness on a componentwide basis.
According to a Department of Army memo, dated April 19, 2004, and
confirmed through our discussions with Army and OSD officials, physical
fitness and body composition data will eventually be tracked in DIMHRS,
in which the Army is the first component to participate. Until DIMHRS
is used, the Army will be unable to report complete and reliable data
on componentwide compliance with the physical fitness examination
requirements. According to Army Reserve officials, physical fitness
data can be tracked in the regional level application software
database, but the information may not be updated by the units in a
timely or consistent manner. This information is then updated in the
Total Army Personnel database, which updates the Individual Training
and Readiness System. In the Army National Guard, the states may use
the personnel database to record the scores and dates of physical
fitness examinations, but not consistently. The Army's first report on
the status of its physical fitness compliance for all its components
will be due March 31, 2007, because the Office of the Under Secretary
of Defense for Personnel and Readiness granted the Army a 2-year
extension for its requirement to report on the physical fitness status
of all members (active, reserve, and guard). The data in this report,
if complete and reliable, could enable DOD to determine the Army's
compliance with the physical fitness examination requirement. According
to the 2004 Department of the Army Memo, if DIMHRS is not on line by
September 2006, the Army will manually report these data.
Compliance with physical fitness examination requirements is tracked at
headquarters level for the Navy Reserve, but we found that the Navy is
unable to report complete and reliable compliance data. The Navy
requires all commands to report their physical fitness assessment data,
including physical readiness test results, through the Physical
Readiness Information Management System (PRIMS). However, we found the
data generated by this system to be unreliable because, according to a
Navy Official, there are about 2,000 duplicate records that need to be
purged and about 25 percent of the Body Composition Assessment scores
have not been reported by unit commanders. Until internal controls are
established to eliminate duplication and ensure completeness of data,
the Navy will be unable to report complete and reliable data on
componentwide compliance with the physical fitness examination
requirement. The Navy submitted its annual report on physical fitness,
due March 31, 2005, to DOD 3 months late, on July 8, 2005. According to
a DOD official, the Navy did not request an extension or provide an
explanation for the late submission. Because the data in this report
came from the PRIMS system that we found to be unreliable, we do not
believe that DOD can reliably use the information in the report to
determine the Navy's compliance with the physical fitness examination
requirement.
The Marine Corps is unable to report complete and reliable data on
compliance with the physical fitness examination because, in contrast
to the Navy, the Marine Corps does not have a dedicated physical
fitness reporting system. Instead, the Marine Corps requires unit
commanding officers to record physical fitness scores in unit diaries,
personnel records, and the Marine Corps Total Force System, a Marine
Corps-wide personnel system. Units that input data into this system are
responsible for reviewing the data and certifying that they are
correct. However, a Marine Corps official indicated that the data are
assumed to be correct when transmitted to higher commands, but no steps
are taken to verify accuracy of the data. As of August 2005, the Marine
Corps had provided DOD with a draft report addressing calendar year
2004 physical fitness scores. According to a DOD official, the Marine
Corps did not request an extension or provide an explanation for the
late draft submission. Further, as of September 2005, the Marine Corps
had not responded to our official request for the annual physical
fitness report. Without an ongoing quality assurance program to
consistently and continuously ensure the completeness and reliability
of the data in the Marine Corps Total Force System, we did not rely on
the data in the draft Marine Corps Physical Fitness Report provided to
DOD.
Although both the Air Force Reserve and Air National Guard each have a
dedicated system to track the physical fitness status of their members,
we found quality assurance procedures lacking, possibly leading to
incomplete and unreliable data with which to track physical fitness
compliance. The Air Force Reserve's software system Program--the Air
Force Fitness Management System (AFFMS)--only tracks fitness program
results on a current basis and only retains data entered from 2004
forward. However, quality assurance procedures are not followed. For
example, there are delays in entering data; compliance of individual
units is only reviewed if there is a question; and headquarters does
not routinely assess members' currency. This program relies on a
fitness program manager within each unit command to monitor program
metrics. According to an AFFMS system official, the only true way of
determining the reliability of the data in this system is to compare
these data with the data in the respective member's personnel files,
and this has not been done. The Air National Guard (ANG) tracking
system for compliance with physical fitness examinations is ANG's
Fitness Age and was first implemented in late 2003, although many ANG
units lagged in their use of Fitness Age until after April 2004. ANG's
Fitness Age database only reflects calendar year information as of a
specific point in time, and does not track or measure performance based
on a running 12-month period. The ANG Fitness Program requires an
assessment on all ANG members once per calendar year. According to ANG
officials, most physical fitness testing is performed within the last
few months of the calendar year. Because the data are cumulative, the
only time that physical fitness information can be assessed for all
members taking the test is at the end of the calendar year. In other
words, most reservists would appear out of compliance until they take
their annual exam even though they are probably still within their 1-
year window for testing. Furthermore, information on the number of
reservists not tested at all or who are overdue is not captured by the
ANG Fitness Age database. According to an ANG official, the
responsibility for managing the physical fitness program rests with the
respective ANG installation's command. The respective ANG installations
(unit commands) have visibility over their respective "overdue"
members. However, ANG headquarters lacks sufficient oversight to assess
compliance. Without ongoing quality assurance programs to consistently
and continuously ensure the completeness and reliability of the data in
the Air National Guard and Air Force Reserve systems, we did not rely
on the data in these systems.
Accountability to Comply with Routine Medical and Physical Fitness
Examination Is Not Always Enforced:
In general, throughout the reserve components, the individual members
are responsible for maintaining their physical and medical fitness and
the unit commanders are responsible for ensuring members' compliance
with medical and physical fitness examinations; however, the reserve
components do not always hold the unit commanders accountable and the
unit commanders do not always enforce the members' compliance.
Accountability for compliance is fragmented at various levels of
command. No centralized oversight exists to hold all levels accountable
ensuring that all requirements are being met. Individual members are
responsible for attending all scheduled examinations and assessments,
seeking timely medical advice when necessary, reporting changes in
their medical health on the annual medical certificate, and
successfully completing the requirements of the physical fitness
examinations. False statements may result in reassignment, discharge,
or other disciplinary action. Unit commanders are responsible for
implementing any administrative and command provisions for
examinations, informing members of the examination requirements,
establishing training programs for physical fitness, taking actions
against reserve members who fail to comply with the requirements, and
reporting the current medical and dental status of reservists through
the applicable tracking systems, and they are ultimately responsible
for the accuracy of medical and physical fitness information relied on
by higher commands. However, reserve components do not always hold the
unit commanders accountable for these responsibilities and the unit
commanders we interviewed expressed concern about the many competing
responsibilities they have, such as meeting training requirements, and
how they must prioritize the use of their limited resources. One unit
commander also expressed concern about enforcing medical and physical
fitness policies if it meant losing a "good soldier" who otherwise
performs his duties well. Without oversight and accountability at the
OSD and respective service and reserve component levels, unit
commanders may not have the incentive or resources to fully enforce the
medical and physical fitness examination requirements and compliance
may suffer.
Indications of Noncompliance with Medical and Physical Fitness
Examination Requirements Exist:
Although DOD can not determine the extent of reserve components'
compliance with routine medical and physical fitness examinations, we
found indications of noncompliance during our site visits and in our
reviews of existing audit reports and investigations. For example, a
limited review of medical files at one Army National Guard and one Army
Reserve location, data from a Navy report, test results of two units in
a Marine Corps battalion, and data from a review conducted by the Air
Force Audit Agency indicate some noncompliance at all components with
the routine medical examination, annual medical certificate, annual
dental examination, and annual physical fitness examination.
Indications of Noncompliance with 5-Year Medical Examination and Annual
Medical Certificate Exist at All Components:
A review of available medical files at one Army National Guard and one
Army Reserve location, data from a Navy report, test results of two
units in a Marine Corps battalion, and data from a review conducted by
the Air Force Audit Agency indicate some noncompliance with the routine
medical examination and the annual medical certificate at all
components. For example, in April 2005 we conducted a review of 39
medical files at an Army National Guard unit that was deployed to Iraq
in 2003 for 1 year. We found that 13 members were not in compliance
with the routine medical examination at the time of our review.
Further, while 36 members were in compliance with the annual medical
certificate at the time of our review, only 3 members were in
compliance with the annual medical certificate prior to the unit being
alerted of their most recent mobilization date for deploying to Iraq.
According to the commander of this unit, there are a number of actions
that need to be accomplished during weekend drills, and with limited
time and resources available, completing routine medical requirements
is low on the long list of priorities. In addition, during June 2005,
we reviewed 175 medical files of an Army Reserve unit that deployed to
Afghanistan in 2003 for 10-month deployment. We found that all but 2
members were in compliance with the 5-year medical examination. While
150 members were in compliance with the annual medical certificate at
the time of our review, not a single member was in compliance with the
annual medical certificate prior to the unit receiving alert orders of
their mobilization. Furthermore, many of the soldiers that we spoke
with during our review stated that they were unfamiliar with the annual
medical certificate. In addition, a February 2005 Army Inspector
General Report noted that virtually all reserve component leaders they
contacted during their review expressed frustration with their
inability to maintain the medical deployability status of their
soldiers using the annual medical certificate process.[Footnote 42]
Leaders noted the certificate only reflects what a soldier is willing
to share. Often the only medical personnel available to review and sign
the certificate is a unit medic, who can do little more than ask if the
data are correct.
In July 2005, the Navy reported that 96.8 percent of reserve members
had completed the routine 5-year medical examination and 94 percent of
reserve members had completed the annual medical certificate. These
high rates are due, in part, to the high priority placed on medical and
dental compliance throughout the Navy Reserve.
Although the Marine Corps Reserve does not currently have componentwide
automated information on medical compliance, it does conduct a periodic
site inspection called the Mobilization Operational Readiness
Deployment Test (MORDT). We reviewed the results of the MORDT at two
units of a Selected Reserve Battalion that had been mobilized. The
first unit test results we reviewed indicated that 98 percent of the
reservists had completed a routine physical examination within 5 years,
and 90 percent had submitted annual health certifications. The second
unit test results also indicated that 98 percent of the reservists had
completed a routine annual physical within 5 years, and 88 percent had
submitted annual health certifications. According to Marine Corps
Reserve officials, all Marine Corps Selected Reserve units are
subjected to an unannounced test prior to mobilization to ensure the
unit can deploy.
The Air Force Audit Agency (AFAA) recently concluded its review of the
Service's Individual Deployment Process, during which it found
significant problems with the Guard's and Reserve's medical records.
Ten Air National Guard and Air Force Reserve installations included in
a sample of 20 installations designed to be able to produce estimates
for all Air Force personnel who were eligible to be deployed during the
90-day window between June 1, 2004, and August 31, 2004, were in
compliance with medical requirements such as, but not limited to,
annual medical assessments and dental examinations. The AFAA reviewed
the medical records and associated documentation for accuracy and
completeness. Based on AFAA's review and analysis of 14,121 eligible
Guard and Reserve members combined, about 13 percent[Footnote 43] were
found to have medical discrepancies in their medical records. At 2 of
the unit commands included in AFAA's review that we also visited in our
review, command officials said that they agreed with the AFAA's
findings and were taking corrective action.
Indications of Noncompliance with Dental Examinations Exist at All
Reserve Components:
Indications of noncompliance with the dental examination requirement
were also present at all the reserve components. For example, as
previously noted, in April 2005, we conducted a review of 39 medical
files of an Army National Guard unit; of these, 33 were not in
compliance with the annual dental examination at the time of our
review. Furthermore, 32 members were not in compliance with the annual
dental examination prior to alert. In June 2005, we visited an Army
Reserve unit to conduct a review of 175 medical files. Although only 13
members were not in compliance with the annual dental examination at
the time of our review, over 130 members were not in compliance with
the dental examination prior to alert.
Other evidence indicates that compliance with dental requirements has
been a particular matter of concern for the Army reserve components.
According to a February 2005 Army Inspector General Report,[Footnote
44] there are examples of reserve component service members with
multiple tooth extractions at nearly every mobilization station.
Furthermore, in cases where members presented dental records during
mobilization, often the only entries are dated to the members' basic
training and initial exams and procedures. We found a stark example of
what happens during mobilization when a member's dental status is
allowed to remain below Class I or II. In one unit we visited, we
interviewed a member who had 30 teeth extracted prior to deployment.
According to the member, although dental screenings were conducted
annually, indicating that he was a dental class III he took no follow-
up action to correct his dental problems because he had no dental
insurance and correcting the problem was not a priority. At the time
this servicemember was being mobilized, a Department of the Army memo
dated December 6, 2002, stated that soldiers assigned to designated
units scheduled to deploy within 75 days of mobilization and identified
as being within dental class III or IV have necessary dental treatment
initiated to bring them up to dental classification II, the deployment
standard.
Although we did not review individual medical and dental records at
Navy and Marine Corps Reserve sites we visited, we did review specific
reports to assess whether these components monitored members' dental
status. We found that the Navy Reserve compliance appears to be
improving. For example, in early July 2005, the Navy reported that 88.6
percent of selected reservists were in a Dental Class I or II category,
an increase over the 69 percent reported in the Dental Class I or II
category in December 2002. We also reviewed MORDT results for two
Marine Corps units during a site visit to a Marine Corps Reserve
Battalion that had been mobilized. We found that test results for the
first unit indicated that 85 percent were categorized as Dental Class I
or II while 77 percent in the second unit were categorized as Dental
Class I or II.
Analysis provided by the AFAA from its review, mentioned earlier,
indicated that about 13 percent[Footnote 45] of the Air National Guard
and Air Reserve members who were eligible to be deployed between June
1, 2004, and August 31, 2004, were found to have discrepancies in their
dental records. In addition to the AFAA review, in 2004 the Air Force
Inspection Agency conducted health services inspections and found
discrepancies in dental readiness classifications in 49 percent of the
37 installations reviewed.
Indications of Noncompliance with Physical Fitness Examination
Requirement Exist at All Reserve Components:
As with the other examination requirements, we also found indications
of noncompliance with the physical fitness examination requirement at
all six components.
During our review in April 2005 we also reviewed 29 physical fitness
files of the Army National Guard unit that deployed to Iraq. Of the 29
physical fitness files we reviewed, only 18 members showed compliance
with the physical fitness examination requirement during 2004. Of these
18 members, 11 passed the physical fitness test and 7 failed. According
to the unit commander, some soldiers possess skills that are greatly
needed for unit continuity and strength and usually outweigh the
ramifications of having to separate the member due to physical fitness
test failures. We also conducted a review in June 2005 of 227 physical
fitness files of the Army Reserve unit that deployed to Afghanistan. Of
the 227 physical fitness files we reviewed, only 117 members showed
evidence of compliance with the physical fitness examination
requirement during 2005. Of these 117 members, 89 passed the physical
fitness test and 16 failed.[Footnote 46] In group discussions held at
this time, members stated that there were no repercussions for failing
the physical fitness test. As previously reported in our 1994
report,[Footnote 47] we also found that physical fitness scores had
been inappropriately changed and servicemembers were not discharged
even after repeated test failures, primarily because commanders placed
more emphasis on maintaining unit strength.
While visiting a Navy Reserve Activity, we obtained a single unit's
physical fitness test results to ensure data were properly maintained
in the Physical Readiness Information Management System. However, when
we asked the Navy Personnel Command to provide a copy of the required
physical fitness report, we learned the report would be submitted to
OSD late. According to a Navy official, the Navy had identified over
2,000 duplicate record entries and estimated that nearly 25 percent of
the body fat scores were missing from the data totals. In its report to
OSD, the Navy reported that it had not mandated separation processing
for individuals who failed the physical fitness test since May 2001.
During a visit to a Marine Corps Reserve Center, we also obtained
information that indicated individual Marine Corps reservists' physical
fitness scores were recorded in the Marine Corps Total Force System.
Subsequent to our visit, however, we learned that the Marine Corps also
provided an unofficial "draft" physical fitness report to the OSD after
the deadline. In order to review Marine Corps physical fitness
statistical data, we requested a copy of the report on April 6, 2005.
As of October 2005, the Marine Corps had not responded to our request.
The Air Force did not meet OSD's required due date in submitting its
first annual report on its assessment of the physical fitness, body
fat, and health promotion program for the active service, the Air
National Guard, and the Air Force Reserve. The Air Force did not submit
its annual report until May 4, 2005. Based on the data provided by the
Air Force for the Air National Guard and the Air Force Reserve, only 83
percent of the force members were tested, with 13.2 percent of those
tested falling into the poor category. However, the Air Force's
assessment of one of its reserve component's statistical data may not
be entirely correct. In its reported statistical information of the
numbers of members tested, those members testing in the poor category
are higher than those numbers directly reported by the Air National
Guard to the Air Force Medical Support Agency, which consolidated the
respective components' data and in turn submitted the overall report to
the Assistant Secretary of Defense for Force Management Policy. In
addition, as discussed earlier, we were unable to determine that the
data used from the Air National Guard and Air Force Reserve databases
that generated these data are reliable.
DOD Lacks Visibility over the Health Status of Reserve Components after
Being Called to Active Duty and the Extent to which Members with
Preexisting Conditions Required Care during Deployment:
DOD does not have complete visibility over the health status of reserve
component members after they are called to duty and is unable to
determine the extent of care provided to those members deployed with
preexisting medical conditions. Despite the existence of various
sources of medical information, DOD has incomplete visibility over
members' health status when called to active duty, primarily because
the reserve components vary in their ability to systematically
identify, track, and report members' medical deployability and the DOD-
wide centralized database cannot provide complete information--both of
which hinder DOD's ability to accurately determine what forces remain
for future deployments. In addition, DOD is unable to determine the
extent to which reserve component members received care for preexisting
medical conditions while deployed; however, evidence suggests that
reserve component members did deploy with preexisting medical
conditions that could not be adequately addressed in theater and that
some of these conditions may have stressed in-theater medical
capabilities.
Visibility over Health Status of Reserve Members after They Are Called
to Active Duty Is Limited:
Although DOD has some visibility over reserve component members after
they are called to active duty or mobilized, this visibility is limited
despite several potential sources of information. For example, the
reserve components vary in their ability to systematically identify,
track, and report information about members' medical deployability,
which limits DOD's visibility over the health status of members. In
addition, although medical information is captured on predeployment
forms for all reserve component members and entered into a DOD-wide
centralized database during mobilization, some data are still missing
and information regarding the reasons why members were found
nondeployable is not captured in a way that can be easily searched
through the database. Moreover, medical referral data captured on the
predeployment forms provide some insight into the care that members may
have required during mobilization, but this care is not always related
to why a member was determined to be medically nondeployable. Some data
on the medical reasons why Army Guard and Reserve members were not
deployed after being activated can be obtained from an analysis of the
Army's medical holdover database, but this information is insufficient
to provide DOD with visibility over members' health status since it is
only gathered on the numbers of Army reserve components held prior to
deployment and this population is diminishing due to positive changes
in Army's medical holdover policy. DOD's limited visibility over
reserve component members' health status when they are called to active
duty could affect planning for future deployments because the pool of
available Guard and Reserve component members from which to fill
requirements for certain skills and grades is dwindling, and members'
health status is deteriorating following deployments.
Reserve Components Vary in Ability to Identify, Track, and Report
Medical Nondeployable Members:
The reserve components vary in their ability to systematically
identify, track, and report members' medical deployability, and only
three reserve components--the Navy Reserve, the Air Force Reserve, and
Air National Guard--can currently identify and track members with both
temporary and permanent conditions that limit medical deployability.
This limited visibility over reserve component members' medical
deployability status hinders DOD's ability to identify the pool of
available Guard and Reserve members who are available for deployment.
The Navy Reserve uses the Medical Readiness Reporting System (MRRS) to
track and report the status of reservists classified as Temporarily Not
Physically Qualified for duty because of an illness, injury, or other
medical condition that should be resolved within 6 months. This system
is also used to track and report the status of reservists, classified
as Not Physically Qualified for duty, with more serious medical
conditions such as cancer or heart disease that will not be resolved in
6 months and may lead to a medical review or board retention decision.
As the Marine Corps Reserve continues to fully implement the Navy's
Medical Readiness Reporting System, it too will have these same
capabilities. Both the Air National Guard and the Air Force Reserve's
medical tracking systems--PIMR and RCPHA, respectively--can identify
and track members with specific medical conditions that limit
deployment; however, neither system can distinguish between temporary
and permanent limitations. In addition, the Air Force has a system
called Military Personnel Data System that captures information on all
medical profiles and can report specific queries on specific categories
such as temporary and permanent conditions. Although the Army tracks
active, guard, and reserve members with medical profiles that limit
deployment through their medical tracking system, MEDPROS, the active
Army and Army Reserve do not presently track members with temporary
medical conditions that render them nondeployable. However, the Army
National Guard is in the process of implementing a system, called the
Medical Non-Deployable Tracking Module (MND-TM), that will track its
members who have a temporary or permanent medical condition that
renders them nondeployable. Army National Guard officials expect all
states to use this system for its members by July 2007. Until all six
reserve components are able to systematically identify and track
members' medical deployability status, DOD will not have the most
accurate information to centrally manage estimating the remaining
available pool of guard and reserve members for future deployments.
Centralized DOD-wide Database Provides Some Visibility over Health
Status During Mobilization, but Data Could Be Further Improved:
DOD has some visibility over reserve component members' medical status
during mobilization through the centralized DOD-wide database operated
by the Army Medical Surveillance Activity (AMSA). All active and
reserve component members are required to complete a medical
predeployment form to document the member's medical deployability
status, which is then forwarded to AMSA for entry into the database.
Thus, information can be obtained from the centralized database on
reserve and active component members who were determined nondeployable
during mobilization due to medical reasons. The member also completes a
health assessment form after deployment. However, we have noted in
previous reports that the centralized database has missing and
incomplete forms. In our last report issued in September 2004,[Footnote
48] we found that for the required forms from reserve component members
(1) not all of the forms had reached AMSA, (2) only some of the forms
that had reached AMSA had been entered into the database, and (3) not
all of the forms contained complete information, thus limiting
analysis.
We also noted that while the components were not in complete compliance
with the requirement to submit pre-and postdeployment assessments, the
number of assessments had grown significantly. During this review, we
found that DOD has continued to make progress toward collecting the pre-
and postdeployment forms. According to AMSA officials, the database
contained about 140,000 assessments at the end of 1999, grew to about 1
million assessments by May 2003, almost doubled at 1,960,125 by June
2004, and was at 2,241,177 by June 2005.
Further, DOD has established a centralized deployment health quality
assurance program to improve data collection and accuracy.[Footnote 49]
Each service has also developed a deployment health quality assurance
program. The department's first annual report, documenting, among other
things, issues relating to predeployment health assessments, was issued
in May 2005. The DOD quality assurance program includes (1) periodic
site visits jointly conducted with staff from the Office of the
Assistant Secretary for Health Affairs and staff from the military
services to assess compliance with the deployment health requirements,
(2) periodic reports from the services on their quality assurance
programs, and (3) periodic reports from AMSA on health assessment data
maintained in the centralized database. The report noted that
centralized management of quality assurance had improved accountability
of the preassessment forms on the part of the services.
For this review, we obtained predeployment information from AMSA
officials based on over 1 million active and reserve component
predeployment health assessment forms collected between November 2001
and June 2005. More than 5 percent of the reserve component and more
than 6 percent of the active component predeployment health assessment
forms did not record the servicemember's deployability status. Of the
approximately 94 percent of forms that were complete, nearly the same
percent of reserve component and active component members were found
medically deployable, 94 percent of the reserve component members
compared to 96 percent of the active component members. Unfortunately,
the forms do not always capture information regarding the reasons why
members were found medically nondeployable or do not capture that
information in a systematic way. For example, although the form has an
entry for a narrative explanation to explain why a member is medically
nondeployable, an AMSA official informed us that these explanations are
often incomplete or not decipherable, and can not be easily
categorized. Furthermore, although the forms do provide space for the
member's deployment destination, this information is not always filled
in because, according to AMSA officials, deployment destination is
often not known by the member or is classified. Therefore, the data
presented here are for all worldwide deployments, including the United
States, and could change after the initial deployment, thus preventing
an analysis by operation.
As seen in table 1, the total nondeployable rate for all six reserve
components was more than 5 percent, while table 2 shows the total
nondeployable rate for the active component was almost 4 percent. While
the Army Reserve had the highest percentage of nondeployable
servicemembers among the reserve components, at about 9 percent, the
active Army had the highest percentage of nondeployable servicemembers
among the active components, at almost 6 percent. According to medical
officials, some of these nondeployable personnel, such as those who had
suffered multiple heart attacks, should have been discharged prior to
the time that they received their mobilization orders. Others had
temporary conditions, such as broken bones and pregnancies, that did
not warrant medical discharges but made the servicemember nondeployable
at the time of the assessment.
Table 1: Service Decisions Concerning Reserve Components'
Deployability, November 2001 through June 2005:
Reserve Components: Army Reserve;
Deployable: 100,286;
Nondeployable: 9,842;
Deployable or nondeployable answer missing on form: 5,578;
Percentage with missing answer: 4.82;
Total number of predeployment health assessments completed: 115,707;
Percentage nondeployable: 8.51.
Reserve Components: Army National Guard;
Deployable: 181,160;
Nondeployable: 10,959;
Deployable or nondeployable answer missing on form: 6,584;
Percentage with missing answer: 3.31;
Total number of predeployment health assessments completed: 198,703;
Percentage nondeployable: 5.52.
Reserve Components: Navy Reserve;
Deployable: 8,597;
Nondeployable: 99;
Deployable or nondeployable answer missing on form: 1,445;
Percentage with missing answer: 14.25;
Total number of predeployment health assessments completed: 10,141;
Percentage nondeployable: .98.
Reserve Components: Air Force Reserve;
Deployable: 13,164;
Nondeployable: 156;
Deployable or nondeployable answer missing on form: 2,341;
Percentage with missing answer: 14.95;
Total number of predeployment health assessments completed: 15,661;
Percentage nondeployable: 1.00.
Reserve Components: Air National Guard;
Deployable: 35,025;
Nondeployable: 243;
Deployable or nondeployable answer missing on form: 3,335;
Percentage with missing answer: 8.64;
Total number of predeployment health assessments completed: 38,603;
Percentage nondeployable: .63.
Reserve Components: Marine Corps Reserve;
Deployable: 3,886;
Nondeployable: 31;
Deployable or nondeployable answer missing on form: 763;
Percentage with missing answer: 16.30;
Total number of predeployment health assessments completed: 4,684;
Percentage nondeployable: .66.
Total;
Deployable: 342,118;
Nondeployable: 21,330;
Deployable or nondeployable answer missing on form: 20,046;
Percentage with missing answer: 5.23;
Total number of predeployment health assessments completed: 383,499;
Percentage nondeployable: 5.56.
Source: GAO analysis of AMSA data.
[End of table]
Table 2: Service Decisions Concerning Active Components' Deployability,
November 2001 through June 2005:
Active Components: Army;
Deployable: 347,057;
Nondeployable: 21,018;
Deployable or nondeployable answer missing on form: 19,451;
Percentage with missing answer: 5.02;
Total number of predeployment health assessments completed: 387,528;
Percentage nondeployable: 5.42.
Active Components: Navy;
Deployable: 20,190;
Nondeployable: 109;
Deployable or nondeployable answer missing on form: 1,627;
Percentage with missing answer: 7.42;
Total number of predeployment health assessments completed: 21,928;
Percentage nondeployable: 0.50.
Active Components: Air Force;
Deployable: 150,045;
Nondeployable: 1,477;
Deployable or nondeployable answer missing on form: 14,544;
Percentage with missing answer: 8.76;
Total number of predeployment health assessments completed: 166,066;
Percentage nondeployable: 0.90.
Active Components: Marine Corps;
Deployable: 47,318;
Nondeployable: 166;
Deployable or nondeployable answer missing on form: 4,191;
Percentage with missing answer: 8.11;
Total number of predeployment health assessments completed: 51,678;
Percentage nondeployable: 0.32.
Active Components: Total;
Deployable: 564,610;
Nondeployable: 22,770;
Deployable or nondeployable answer missing on form: 39,813;
Percentage with missing answer: 6.35;
Total number of predeployment health assessments completed: 627,200;
Percentage nondeployable: 3.63.
Source: GAO analysis of AMSA data.
[End of table]
Medical Referral Data Provide Insight on Care Provided during
Mobilization:
The predeployment health assessment forms capture information on
specific medical referrals given to members by the reviewing health
care official during mobilization, which is useful in gaining some
insight into the care that members may have required during
mobilization. These data are not as helpful in determining why a member
was not medically deployable since they are not always related to why a
member was determined to be nondeployable. According to a senior OSD
official, although any indicated referral may be related to a
disposition of nondeployable, this is not always the case. Three common
scenarios illustrate this relationship: (1) a member is found to be
clearly nondeployable from a medical standpoint, and no referral is
made; (2) a member is referred for further evaluation for a condition
for which deployability is questionable, in which case there is a
direct relation between the referral and the determination of
deployable or nondeployable; or (3) a member is found to be deployable,
but has a minor medical issue for which the health provider provides a
referral for treatment. According to a senior OSD official, the last
scenario is a fairly uncommon reason for a referral. Examples might
include a referral for a routine preventive test, such as a Pap test in
a gynecological clinic. The Pap test is a desired preventive medical
test, but depending on the date and result of the last Pap exam and the
individual's personal history and risk factors, it is not always
necessary to perform one prior to deployment.
More than 50,000 referrals were made on the predeployment health
assessments from November 2001 through June 2005 for both the active
and reserve components. As shown in table 3, of the 21,000 forms with
referrals for reserve component members, the referral rate averaged
more than 5 percent. As shown in table 4, of the 24,633 forms with
referrals for their active duty counterparts, the referral rate was
about 4 percent. Within the reserve components, the Army Reserve had
the highest referral rate at nearly 8 percent, while the Air National
Guard and Air Force Reserve had the lowest rates, both at less than 1
percent.
Table 3: Total Predeployment Referral Rate by Reserve Component,
November 2001 through June 2005:
Reserve component: Army National Guard;
Total number of predeployment events with referrals: 11,609;
Total predeployment referral rate: 5.84.
Reserve component: Army Reserve;
Total number of predeployment events with referrals: 8,750;
Total predeployment referral rate: 7.56.
Reserve component: Air National Guard;
Total number of predeployment events with referrals: 201;
Total predeployment referral rate: 0.52.
Reserve component: Air Force Reserve;
Total number of predeployment events with referrals: 145;
Total predeployment referral rate: 0.93.
Reserve component: Navy Reserve;
Total number of predeployment events with referrals: 211;
Total predeployment referral rate: 2.08.
Reserve component: Marine Corps Reserve;
Total number of predeployment events with referrals: 84;
Total predeployment referral rate: 1.79.
Reserve component: Total;
Total number of predeployment events with referrals: 21,000;
Total predeployment referral rate: 5.48.
Source: GAO analysis of AMSA data.
[End of table]
Table 4: Total Predeployment Referral Rate by Active Component,
November 2001 through June 2005:
Active component: Army;
Total number of predeployment events with referrals: 20,312;
Total predeployment referral rate: 5.24.
Active component: Air Force;
Total number of predeployment events with referrals: 3,047;
Total predeployment referral rate: 1.83.
Active component: Navy;
Total number of predeployment events with referrals: 572;
Total predeployment referral rate: 2.61.
Active component: Marine Corps;
Total number of predeployment events with referrals: 702;
Total predeployment referral rate: 1.36.
Active component: Total;
Total number of predeployment events with referrals: 24,633;
Total predeployment referral rate: 3.93.
Source: GAO analysis of AMSA data.
Note: Predeployment Health Assessment forms may contain no referrals,
one referral, or multiple referrals per completed form.
[End of table]
There are 18 categories of referrals that can be checked on the
predeployment form, of which 1 is "other" and does not provide any
further detail. As seen in figure 1, the top 3 medical referrals for
the reserve components were "other," "dental," and "eye," whereas the
top 3 referrals for active components were "other," "dental," and
"orthopedics." The rate of medical referrals for the reserve components
was almost 40 percent and for the active components was almost 50
percent.
Figure 1: Rate of Medical Referrals by Type for Active and Reserve
Components from November 2001 through June 2005:
[See PDF for image]
[End of figure]
Although the AMSA referral data do provide some insight into the
medical care required during mobilization, the referral data are not
detailed enough to determine the type of medical referral or determine
the reason for nondeployment.
Army Medical Holdover Database Provides Data on Activated Members Who
Were Not Deployed Due to Medical Problems:
The Army's medical holdover database, a module within the Medical
Operational Data System (MODS), does provide DOD with a snapshot of
data about the number of Army National Guard and Reserve members who
were not deployed after being called to active duty because of medical
problems and the medical reasons why they were not deployed after being
activated. Although all of the services may keep reserve component
members on active duty if they incur an injury in the line of duty
following deployment, only the Army has held reserve component members
in need of medical care at military treatment facilities prior to
deployment. These servicemembers are referred to as the medical
holdover population. Because of the large numbers of activated Army
National Guard and Army Reserve members placed in medical holdover by
the Army in the early part of Operation Iraqi Freedom, the Army Office
of the Surgeon General created a module in an existing database to
track them. We examined the Army medical holdover data to obtain
information about the possible reasons why servicemembers were found to
be medically nondeployable. However, the data cannot provide complete
visibility over members' health status because the population receiving
medical care from the Army prior to deployment is diminishing due to
changes in Army's medical holdover policy. Further, until January 2005,
MODS was not used consistently by all case managers[Footnote 50]
responsible for servicemembers in medical holdover.
Between December 2002 and October 2003, 4,850 activated Army reserve
component members were found medically nondeployable and kept on active
duty until their medical problems had been resolved and they were
returned to full duty or until they had been referred to a medical
board and discharged from the Army. In October 2003, the Army changed
its policy to allow the demobilization of personnel who were found to
be nondeployable within the first 25 days of activation. In accordance
with this policy, reserve component servicemembers identified in the
first 25 days as having a medical condition that renders the individual
nondeployable may be released from active duty immediately. As a result
of this policy change, the Army was able to demobilize reserve
component members who were found to be nondeployable within the first
25 days of their mobilization. The change also reduced the inflow of
reserve component members on active duty with medical problems who were
identified during the predeployment health assessment process. As of
August 11, 2005,[Footnote 51] only 860 reserve component
members[Footnote 52] were in a medical holdover status as a result of a
medical condition found prior to deployment.
As shown in figure 2, the most common medical condition that has
prevented a reserve component member from deployment[Footnote 53] is
orthopedic in nature--accounting for 56 percent of the 860 Army
National Guard and Army Reserve members who were found medically
nondeployable and placed in a medical holdover status--followed by
internal medicine at 16 percent, and neurological problems at 8
percent.
Figure 2: Medical Conditions of Army National Guard and Army Reserve
Members in a Medical Holdover Status as of August 11, 2005:
[See PDF for image]
[End of figure]
Despite the more specific information about medical status that can be
obtained by reviewing these medical holdover data, the data are fairly
new and limited to those held at medical treatment centers.
Lack of Visibility over Reserve Component Members' Health Status Could
Affect Planning for Future Deployments:
Although senior military officials at various levels of command told us
that the health status of reserve component members did not affect
deployment schedules, the extent to which unit commanders have had to
find replacement members to fill in for members who were medically
unqualified upon alert, the reasons why, and how, or if, this impacted
planning of operations in Iraq and Afghanistan are unknown. However,
DOD's lack of visibility over reserve component members' health status
when they are called to active duty could affect planning for future
deployments as the demand for troops for the Global War on Terrorism
continues.
The Army has had to transfer reserve component personnel from
nonmobilized units to mobilized units to meet mission requirements. For
example, the Army Inspector General reported in February 2005 that with
increasing frequency, Army units identified for alert and mobilization
had previously provided members to other units. The report noted that
frequently more than half of a deploying unit's personnel had been
transferred into the unit to meet personnel requirements. This "ripple
effect" is occurring across the Army reserve force, and each subsequent
mobilization requires more and more personnel transfers to meet
personnel requirements. The need for these personnel transfers is
largely due to an outdated Cold War strategy that planned to use the
reserve forces as a later deploying force and therefore did not give
them full resources. As more units are used for this "cross-leveling",
it becomes even more important that the Army have good visibility over
the health status of the remaining reserve component members.
In addition, as shown in table 5, the health status has declined for
active and reserve components after returning from deployment as shown
by data from the pre-and postdeployment health assessments. The Army
National Guard and Army Reserve had the highest percentage of
servicemembers indicating their health as fair to poor on the
postdeployment health assessment.
Table 5: Rate of Servicemembers' Health Status as Recorded on Pre-and
Postdeployment Forms for Active and Reserve Components from November
2001 through June 2005:
Reserve component:
Military component: Army Reserve;
Predeployment: good to excellent: 95.77;
Postdeployment: good to excellent: 87.05;
Predeployment: fair to poor: 2.70;
Postdeployment: fair to poor: 12.30.
Military component: Army National Guard;
Predeployment: good to excellent: 96.57;
Postdeployment: good to excellent: 89.07;
Predeployment: fair to poor: 2.27;
Postdeployment: fair to poor: 10.31.
Military component: Marine Corps Reserve;
Predeployment: good to excellent: 98.36;
Postdeployment: good to excellent: 89.90;
Predeployment: fair to poor: 0.99;
Postdeployment: fair to poor: 8.95.
Military component: Air National Guard;
Predeployment: good to excellent: 99.13;
Postdeployment: good to excellent: 97.43;
Predeployment: fair to poor: 0.42;
Postdeployment: fair to poor: 1.73.
Military component: Air Force Reserve;
Predeployment: good to excellent: 99.00;
Postdeployment: good to excellent: 96.49;
Predeployment: fair to poor: 0.40;
Postdeployment: fair to poor: 2.16.
Military component: Navy Reserve;
Predeployment: good to excellent: 98.60;
Postdeployment: good to excellent: 93.67;
Predeployment: fair to poor: 0.64;
Postdeployment: fair to poor: 5.08.
Active component:
Military component: Army;
Predeployment: good to excellent: 95.00;
Postdeployment: good to excellent: 90.53;
Predeployment: fair to poor: 3.44;
Postdeployment: fair to poor: 8.32.
Military component: Marine Corps;
Predeployment: good to excellent: 97.51;
Postdeployment: good to excellent: 93.49;
Predeployment: fair to poor: 1.74;
Postdeployment: fair to poor: 5.59.
Military component: Air Force;
Predeployment: good to excellent: 98.82;
Postdeployment: good to excellent: 97.73;
Predeployment: fair to poor: 0.86;
Postdeployment: fair to poor: 1.73.
Military component: Navy;
Predeployment: good to excellent: 96.88;
Postdeployment: good to excellent: 94.27;
Predeployment: fair to poor: 2.55;
Postdeployment: fair to poor: 5.08.
Source: GAO analysis of AMSA data.
[End of table]
As the pace of operations for the reserve forces continues to be high
and the health status of returning members is diminished, it becomes
even more important that DOD has good visibility over the availability
of remaining units. Improved visibility and tracking of the health
status and medical deployability of these members is a key component in
the calculation of the members available for planning future
deployments.
Extent to which Members with Preexisting Medical Conditions Required
Treatment during Deployment Cannot Be Determined:
DOD cannot determine the extent to which reserve component members
received care for preexisting medical conditions while deployed in
theater[Footnote 54] because DOD has not determined what preexisting
medical conditions may be allowed into specific theaters of operations.
The purpose of examining members and properly screening them at the
mobilization stations is to help ensure that members are medically and
physically fit to deploy and do not have any condition that would
adversely affect the mission. As noted in DOD guidance,[Footnote 55]
fitness specifically includes the ability to accomplish the task and
duties unique to a particular operation, and the ability to tolerate
the environmental and operational conditions of the deployed location.
Specific medical deployment criteria for proper screening are essential
for determining preexisting medical conditions that can not be
adequately addressed in theater and could stress in theater medical
capabilities. While evidence suggests that members did deploy with
preexisting conditions, the total impact of this is unknown.
While Specific Deployment Criteria for Operations Enduring Freedom and
Iraqi Freedom Continue to Evolve, Tracking of Known Preexisting
Conditions Has Not Begun:
Developing and updating medical criteria for a specific theater of
operations are the responsibilities of the combatant commands--for
Operation Enduring Freedom and Operation Iraqi Freedom this is U.S.
Central Command (CENTCOM). The CENTCOM medical deployment criteria have
been evolving over the course of these operations. CENTCOM has updated
this guidance six times throughout these operations to include more
specific guidance to the theater of operations; the last update was
issued in January 2005. During the initial mobilizations for these
operations, the services were dependent on CENTCOM general deployment
criteria issued in May 2001, which did not identify medical conditions
that would render a member medically unfit for these operations. In the
absence of specific guidance early on during the operations, the
services relied upon their own medical deployment criteria. For the
Army, specific criteria did not exist until February 2005.[Footnote 56]
The original CENTCOM deployment criteria made a general statement that
all personnel must be assessed and determined to be medically and
psychologically fit for worldwide deployment to a combat theater and
that the in-theater health infrastructure provides only limited medical
care. Not until May 2004 did CENTCOM update its deployment criteria to
include more specific guidance. This updated guidance stated that
servicemembers who have existing medical conditions may deploy if all
of the following conditions were met: (1) an unexpected worsening of
the condition is not likely to have a medically grave outcome; (2) the
condition is stable; and (3) any required ongoing health care or
medications must be immediately available in theater in the military
health system, and have no special handling, storage, or other
requirements, such as electrical power. The criteria provided a list of
conditions that may preclude medical clearance for DOD civilians and
contractors (including current heart failure, history of heat stroke,
and uncontrolled hypertension); however, according to CENTCOM
officials, this list of conditions did not apply to servicemembers
because they were already covered by service-specific guidelines. The
most recent CENTCOM deployment criteria applicable to all
servicemembers and DOD civilians and contractors were issued in January
2005, and update theater-specific immunization requirements and provide
more detailed guidance on contact lens wear, among other things. As
these policies are developed, the combatant command is to provide them
to the services, which are then responsible for determining how they
implement the screening requirements in terms of screening their
deploying forces, including activated reservists.
Because DOD has not determined what preexisting conditions may be
allowed into a specific theater of operations, it has not known what
preexisting conditions to track. As noted, the medical deployment
criteria for the current theater of operations have been evolving, but
specific medical deployment criteria have not been developed for other
potential theaters of operation. However, some preexisting medical
conditions may be common to all theaters of operation. DOD has not
determined this. Further, although DOD has a number of systems for
tracking medical conditions in theater, the current databases have not
been modified to capture data on known preexisting conditions for this
specific operation. For example, the Joint Medical Workstation (JMeWS)
provides medical treatment status and medical surveillance information,
as well as tracks and reports patient location within a theater of
operations and during evacuation from frontline medical units to
stateside medical treatment facilities. The U.S. Transportation Command
(TRANSCOM) utilizes the TRANSCOM Regulating Command and Control
Evacuation System (TRAC2ES) to document patient movements, such as
medical evacuations. The Joint Patient Tracking Application (JPTA) was
initially designed for use within Landstuhl Regional Medical Center in
Germany as a way to manage Operations Enduring Freedom and Iraqi
Freedom patients. In 2004, the services were directed by the Assistant
Secretary of Defense for Health Affairs to implement JPTA at military
treatment facilities in theater and the continental United States to
improve patient tracking and management. The Disease Nonbattle Injury
(DNBI) rates for the services in Operations Enduring Freedom and Iraqi
Freedom are tracked in the DNBI database by the Air Force Institute for
Operational Health. We did not evaluate these systems since they do not
distinguish care provided for preexisting medical conditions.
Evidence Suggests that Reserve Component Members Have Been Deployed
into Theater with Preexisting Medical Conditions:
Although DOD does not systematically develop or report information
about the extent of care that was provided in theater to reserve
component members for preexisting medical conditions,[Footnote 57]
senior military medical officials who served in theater have provided
examples of reserve component members who were deployed with
preexisting medical conditions that could not be adequately addressed
in theater. Some officials told us that such treatments strained in
theater medical capabilities and infrastructure.
According to a senior military official in the surgeon's office of the
commander in chief of the U.S. Central Command (CENTCOM), there were
many instances of individuals, from all services, who deployed into the
Iraq and Afghanistan theater of operations with conditions for which
they should have been considered nondeployable. Also, medical officials
from both the Army and Navy cited examples of conditions seen in
theater that should have rendered members nondeployable. Among the
examples cited were members with a history of heart attack, severe
asthmatics (the desert conditions were not suitable for these members),
severe hypertension, a woman 4 months into chemotherapy for breast
cancer, and a man who had received a kidney transplant 2 weeks prior to
deploying. Other examples included cases involving members deployed
with sleep apnea requiring machines that are run by electricity, even
though electricity was either unavailable or unpredictable. Another
soldier, we were told, who arrived in theater was diabetic and required
an insulin pump for treatment. We were also told of a number of
psychiatric patients who were suffering from conditions such as bipolar
disorder who should not have been in the desert because the medications
that they were taking caused them to sweat profusely. One Air Force
Reserve medical official who served in theater preparing members to be
medically evacuated estimated that of the approximate 2,000 reservists
she helped to evacuate, 10 percent being evacuated were due to
preexisting conditions such as diabetes and heart problems, with the
most common condition being diabetes. The commander of an Army Guard
unit deployed to Iraq told us about a member who had deployed with a
preexisting knee problem for which he had to be returned to the United
States to correct. The issue was eventually resolved and the member was
allowed to redeploy with his unit.
According to a September 2004 Air National Guard Surgeon General
memorandum,[Footnote 58] unacceptable dental health should preclude a
member from deploying under any circumstances because dental resources
do not exist in theater. However, the Air National Guard's Surgeon
General has noted that dental emergencies are historically and
currently the most common preventable reason for loss of manpower in
the wartime theater.[Footnote 59] In addition, the Air Force's Air
Surgeon Chief of Medical Services Directorate commented on January 17,
2003, in response to a case involving an Air National Guard member who
had been sent into theater with an obvious major preexisting dental
condition, that it is unreasonable to expect deployed doctors and
dentists to perform remedial procedures and provide care that should
have been accomplished at home because it takes too much time away from
treating injured and ill in theater, and it results in lost man hours
for the gaining unit that it needs to accomplish its war-fighting
requirements. In our small group discussions with Army National Guard,
one servicemember said that he was told that he would receive dental
care in theater, although this care was never provided. At one Air
National Guard unit command we visited, officials informed us of a
member who was mobilized and subsequently deployed with preexisting
dental problems in late 2003, because (1) the dental condition was not
disclosed by the member and (2) the unit command did not have a current
dental exam in his medical records to prove otherwise. The member would
not have been deployed had his true dental condition been initially
identified, but he received substantial dental work while
deployed.[Footnote 60] According to a unit command official, the member
was subsequently returned to his unit command because his dental costs
and related work downtime were excessive.
Other Reasons Members May Have Arrived in Theater with Preexisting
Conditions:
In addition to a lack of specific guidance from CENTCOM to the services
early in the operations, military medical officials told us other
reasons why members may have arrived in theater with preexisting
medical conditions. First, military officials stated that in some cases
members did not disclose their preexisting medical conditions because
they wanted to serve their country. A Navy official, for example,
stated that a Navy officer with hypertension did not disclose his
medical condition in order to deploy to Iraq to support Operation Iraqi
Freedom. Because the officer's medical condition worsened in Iraq, the
Navy had to return him to his home unit and find a replacement to fill
his position. We were also told of members who arrived in theater with
preexisting conditions with the expectation that they would be taken
care of while they were there. For example, a senior medical official
stated that one servicemember arrived in theater with one kidney and in
need of dialysis, which was not available in theater. Early in
operations several servicemembers with hernias were deployed with the
expectation that the surgery would be conducted in theater.
It is important to have up-to-date medical criteria specific to a
theater of operations to alert members to changing condition in theater
or new information on vaccinations, for example. Developing and
updating medical criteria for a specific theater of operations is the
responsibility of the commander in chief of the combatant command--in
this case, CENTCOM. As these polices are completed and updated, the
combatant command is to provide them to the services, who are then
responsible for determining how they implement the requirements in
terms of screening their deploying forces including activated
reservists.
Conclusions:
The findings we present in this report are not new. In the aftermath of
the first Persian Gulf War, a number of DOD and GAO studies were issued
that identified problems with guard and reserve personnel being
medically and physically fit for duty. DOD agreed with many of the
studies' findings and recommendations but never developed a plan with
goals, time frames, and measurable results to improve visibility over
reserve component members' health status. At times, Congress has
stepped in and directed DOD to make a number of improvements,
especially for quality assurance and tracking of health assessment data
collected before and after a member's deployment. Congress recently
directed OSD to develop and implement a comprehensive plan to improve
management of the health status of the reserve component. The
importance of such a plan has become even more important in the current
environment, where the pool of guard and reserve members with the right
skills from which to fill requirements for DOD's overseas and domestic
commitments is dwindling.
Further, many of DOD's personnel policies, including its medical
policies, are outdated, as they are based on Cold War strategy that
allowed the reserve force more time to mobilize before deployment. Now
the reserve force deploys with the active force and is expected to be
medically and physically fit when called to duty. The lack of oversight
of reserve members' health status, however, does not appear to be
unique to the reserve component. Oversight, as seen in the area of
enforcing DOD's reporting requirement on the status of physical fitness
for both the active and reserve components, has not taken place. No
repercussions exist if a service does not provide this report on time,
nor are there any deadlines for the annual report to be submitted to
OSD.
OUSD/P&R has the authority to set medical and physical fitness policy
and processes to oversee this area; however, OUSD/P&R has not taken
action to exercise its authority to address these long-standing
problems.
Recommendations for Executive Action:
As DOD proceeds to develop a comprehensive plan for improving
management over the health status of the reserve components in response
to the Ronald W. Reagan National Defense Authorization Act for Fiscal
Year 2005, we recommend six actions.
To have visibility over reserve components' compliance with routine
medical and physical fitness examinations, we recommend that the
Secretary of Defense:
* direct the Under Secretary for Personnel and Readiness, in concert
with the Assistant Secretary for Health Affairs and the Principal
Deputy to the Under Secretary, to establish a management control
framework and execute a plan for issuing guidance, establishing quality
assurance for data reliability, and tracking compliance with routine
medical and physical fitness examinations; and:
* direct the Under Secretary for Personnel and Readiness, in concert
with the Principle Deputy who oversees the Office of Morale, Welfare,
and Recreation, to take steps to enforce the service reporting
requirement on the status of members' physical fitness in conjunction
with the actions taken in the first recommendation.
To improve DOD's visibility over reserve components' health status
after they are called to duty, we recommend that the Secretary of
Defense:
* direct the Under Secretary of Defense for Personnel and Readiness, in
concert with the Assistant Secretary of Health Affairs, to also oversee
the development of the reserve components' tracking systems to identify
and track members' temporary and permanent medical conditions that
limit deployability; and:
* direct the Under Secretary of Defense for Personnel and Readiness, in
concert with the Assistant Secretary of Health Affairs, to modify the
medical predeployment forms to better capture reasons for nondeployment
and medical referrals.
To help prevent the deployment of reserve component members with
preexisting medical conditions that could adversely affect the mission
and strain resources in theater, and to provide visibility over those
members deployed with preexisting conditions for which treatment can be
provided in theater, we recommend that the Secretary of Defense:
* direct the Chairman of the Joint Chief of Staff to determine what
preexisting medical conditions should not be allowed into specific
theaters of operations, especially during the initial stages of the
operation, and to take steps to ensure that each service component
consistently utilizes these as criteria for determining the medical
deployability of its reserve component members during mobilization;
and:
* direct the Chairman of the Joint Chief of Staff, in concert with the
service secretaries, to explore using existing tracking systems to
track those who have treatable preexisting medical conditions in
theater.
Agency Comments and Our Evaluation:
In written comments on a draft of this report, DOD did not concur with
our first and fourth recommendations, partially concurred with our
fifth recommendation, and concurred with our second, third, and sixth
recommendations. DOD did not concur with our recommendation that it
establish a management control framework and execute a plan for issuing
guidance, establishing quality assurance for data reliability, and
tracking compliance with routine medical examinations. DOD did not
state that it disagreed with our findings; however, DOD stated that it
had initiatives underway that addressed our recommendation. DOD further
noted that because policies, programs, and instructions are already in
place or in process, it did not see the need for any additional action.
We disagree with DOD's conclusion because, based on our review, we do
not believe that DOD's initiatives are far enough along to dismiss
further action, and we continue to believe that our recommendation has
merit. We agree that the initiatives DOD cited in its written comments
are positive steps toward correcting the identified problems, but
management and planning remain a concern. We have not seen enough
evidence to agree that DOD has put in place a management control
framework that will enforce holding all responsible levels accountable,
ensuring that all routine medical requirements are being met, and that
complete and reliable data are being entered into the appropriate
tracking systems. As noted in our report, the problems with determining
the health status of the reserve force were revealed during Operations
Desert Shield and Desert Storm, and in the decade that has passed since
then DOD has made little progress to correct the identified problems.
As a result, in 2004, Congress directed DOD to establish a Joint
Medical Readiness Oversight Committee to oversee the development and
implementation of a comprehensive medical readiness plan. As also noted
in our report, the committee held its first meeting in February 2005,
and a plan to improve medical readiness was being developed during this
review. We do not believe that a committee can be held accountable for
ensuring that such actions take place. Ultimately, the Under Secretary
of Defense for Personnel and Readiness, in concert with the Assistant
Secretary for Health Affairs, are accountable for enforcing the
requirements for routine medical examinations.
Moreover, DOD stated that it has established a new quality assurance
program that monitors electronic data with validation through medical
record reviews of a wide range of force health protection measures. We
did not find this to be true during our review. With the exception of
the Navy Reserve, the reserve components do not monitor electronic data
of routine medical examinations with validation through medical record
reviews. Further, we found the data in the reserve components' tracking
systems to be unreliable for purposes of determining compliance with
routine medical examinations. As noted in our report, compliance with
these routine medical examinations is the first step toward determining
who is medically fit or ready for duty. DOD stated that its compliance-
monitoring Individual Medical Readiness program regularly reports the
overall medical readiness status for each servicemember. However, we
found that the Individual Medical Readiness program's outcomes are
derived from data in the reserve components' tracking systems, which we
have found to be unreliable, with the exception of the Navy Reserve,
for the purposes of determining compliance with routine medical
examinations. DOD stated that its Individual Medical Readiness
program's data are being incorporated into overall unit readiness
status reports, providing visibility of reserve component medical
readiness throughout the line command structure. We believe that until
top management at DOD ensures that complete and reliable data on
routine medical examinations are being entered into its tracking
systems, DOD and Congress will continue to have a false picture of
medical readiness for the reserve components. We believe that our first
recommendation still has merit.
DOD concurred with our recommendation that DOD take steps to enforce
the services' reporting requirement on the status of their members'
physical fitness. DOD stated that DOD instruction 1308.3, dated
November 5, 2002, among other things, requires the active and reserve
components to provide an annual report to the Principal Deputy of the
OUSD/P&R not later than March 31. DOD stated that the Air Force, the
Navy, and the Marine Corps have submitted their reports. DOD noted that
exceptions to the reporting requirement for the Air Force and the Army
had been approved. However, during our review we were told that none of
the reports had been submitted to the Principal Deputy as required. We
raised concerns in this report about the data reliability of the
tracking systems for physical fitness. We found that the reserve
components are unable to report complete and reliable data on
compliance with routine physical fitness examinations on a
componentwide basis due to incomplete and unreliable data. Just as we
found with routine medical examinations, we also found that DOD lacked
quality assurance of the data on compliance with physical fitness
examinations in its tracking systems. We do not know what data
reliability issues DOD will cite in its annual reports on physical
fitness. We note that the responsible office for physical fitness
oversight, the Office of Morale, Welfare, and Recreation, does not
participate in the Joint Medical Readiness Oversight Committee that is
directed to oversee improvements in medical readiness, nor are we aware
of any DOD plans to include improvements in the oversight of physical
fitness in its comprehensive medical readiness plan. Therefore, we have
expanded our first recommendation to include routine physical fitness
examinations in the actions to be addressed.
DOD concurred with our recommendation that DOD oversee the development
of the reserve components' tracking systems to identify and track
members' temporary and permanent medical conditions that limit
deployability. DOD stated that it is already actively adapting existing
systems, and in some cases creating new ones, that can be used to track
the medical status of active and reserve members, to include those
known conditions that could limit an individual's deployability. DOD
noted that it continues to pursue better integration between medical
and personnel data systems to improve visibility regarding deployment-
limiting medical conditions, whether temporary or permanent, but the
overall effectiveness will continue to be limited by lack of access to
civilian medical records of reserve component members.
DOD did not concur with our recommendation that DOD modify the medical
predeployment form to better capture reasons for nondeployment and
medical referrals. DOD stated that the best sources of accurate
information about what medical reasons kept service members from
deploying are the permanent medical records. This may be the case, but
we continue to believe our recommendation has merit because DOD has no
way to systematically analyze the information to determine why
servicemembers are medically nondeployable. Because the predeployment
form is used to document whether a servicemember is deployable, this
existing form could be modified to better capture the reasons for
determining why a servicemember is determined nondeployable. Although
the form has an entry for a narrative explanation to state why a member
is medically nondeployable, AMSA officials informed us that these
explanations are often not decipherable, incomplete, and can not be
easily categorized. DOD also stated that the existing predeployment
form already includes a list of the most common referral categories to
simplify the documentation process for the health care provider. In
addition, DOD also noted that data from the forms are captured
electronically and are readily available to monitor for trends in
referral patterns, among other things. We do not believe that any
meaningful analysis for referrals can be determined from these forms
because we found that the top medical referral category for the reserve
and active components was "other". This heavy use of the category
"other" does not provide any insight as to what medical care a member
is receiving after being called to duty. Given that the rate of medical
referrals for the reserve components was almost 40 percent and for the
active components was almost 50 percent, we continue to believe that
DOD should modify the predeployment form to better capture reasons for
nondeployment and medical referrals.
DOD partially concurred with our recommendation that DOD determine what
preexisting medical conditions should be allowed into a specific
theater of operations, especially during the initial stages of
operations, and take steps to consistently utilize these criteria for
determining medical deployability. DOD stated that certain conditions
clearly should render a member nondeployable, and the services have
made strides in defining these conditions and incorporating them into
their applicable policies and procedures. But DOD also noted that due
to the ever-changing nature of a theater of operations and the inexact
nature of medicine, a list of nondeployable preexisting conditions will
never be fully comprehensive or fully enforceable. We agree that a list
of nondeployable preexisting medical conditions can never be fully
comprehensive; however, we still believe DOD could establish a list of
what preexisting medical conditions should be allowed into specific
theaters of operations, especially during the initial stages of
operations, so that in future deployments DOD would not experience
situations such as those that occurred with members being deployed into
Iraq who clearly had preexisting conditions that should have prevented
their deployment.
DOD concurred with our recommendation that DOD explore using existing
tracking systems to track those who have treatable preexisting medical
conditions in theater. DOD noted that refinements to medical tracking
system are ongoing. We wish to note that before DOD's tracking systems
can be used to track those who have treatable preexisting medical
conditions in theater, DOD must determine what preexisting medical
conditions should be allowed into a specific theater of operations as
called for in our fifth recommendation.
DOD noted in its overall comments that the reserve and active forces
use many of the same reporting tools within each service and face the
same basic challenges in ensuring data quality. DOD stated that where
tracking systems are shared, the reserve components depend on the
active components to develop and fund those systems, and that priority
for deployment of large systems has historically been given to the
active component. DOD also pointed out that our report indicates that
the health status of members deteriorates with multiple deployments and
that the data we used are self-reported and should be taken with great
caution and in the proper context. We used the self-reported data from
postdeployment health assessments to help demonstrate the importance of
good visibility over the reserve forces. We noted that the demand for
reserve personnel, especially within the Army components, continues,
and the pool of reserve members used to fill requirements is dwindling.
Further, the health status of returning reserve and guard members is
not as good as it was before deployment as our analysis of the pre-and
postdeployment health assessments showed. Therefore, it becomes even
more important that DOD have good visibility over the health status of
remaining reserve force to help determine what is left for future
deployments.
DOD's comments are reprinted in their entirety in appendix II.
We are sending copies of this report to the Secretary of Defense; the
Secretaries of the Army, the Navy, and the Air Force; the Commandant of
the Marine Corps; the Chairman of the Joint Chiefs of Staff; and the
Director, Office of Management and Budget. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on the GAO Web site at http://www.gao.gov.
If you or your staff has any questions concerning this report, please
contact me at (202) 512-5559 or stewartd@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix III.
Derek B. Stewart:
Director, Defense Capabilities and Management:
[End of section]
Appendix I: Scope and Methodology:
To assess the Department of Defense's (DOD) ability to determine the
reserve components' compliance with routine medical and physical
fitness examinations, we reviewed federal statutes and Office of the
Secretary of Defense (OSD) applicable directives and instructions to
identify and understand the roles and responsibilities of the offices
within DOD for management of the health status of the reserve
components. We discussed these statutes and guidance with senior
officials in the Office of the Under Secretary of Defense for Personnel
and Readiness. We reviewed and discussed service policies and
regulations for medical and physical fitness with military officials
within the service surgeons' general offices and other service
headquarters' officials responsible for physical fitness in the service
personnel and operations functions. We also reviewed and discussed
reserve component policies and guidance for medical and physical
fitness examinations with officials within the reserve component
surgeons' general offices and other reserve component officials
responsible for physical fitness in the respective reserve component
personnel and operations functions. We interviewed cognizant officials
involved with policy development, administration, tracking, and
reporting on compliance with medical and physical fitness examinations
from the following offices or commands:[Footnote 61]
Office of the Secretary of Defense:
* Assistant Secretary of Defense for Health Affairs, Deployment Health
Support Directorate;
* Assistant Secretary of Defense for Reserve Affairs; and:
* Principal Deputy Under Secretary of Defense for Personnel and
Readiness, the Office of Morale, Welfare, and Recreation.
Army:
* Assistant Secretary of the Army, Manpower and Reserve Affairs;
* U.S. Army Office of the Surgeon General and Commanding General, Army
Medical Command;
* U.S. Army Reserve Command, Fort McPherson, Georgia;
* National Guard Bureau;
* Army National Guard;
* First U.S. Army, Fort Gillem, Georgia;
* U.S. Army Forces Command, Fort McPherson, Georgia;
* Army Fitness School, Ft. Benning, Georgia;
* Fifth U.S. Army, Fort Sam Houston, Texas;
* U.S. Army Medical Command, Fort Sam Houston, Texas;
* U.S. Army Dental Command, Fort Sam Houston, Texas;
* Army Audit Agency; and:
* MEDPROS Program Office.
Navy:
* Assistant Secretary of the Navy, Manpower and Reserve Affairs;
* Office of the Chief of Navy Operations;
* Office of the Chief of Navy Reserve;
* Bureau of Medicine and Surgery;
* Commander Navy Reserve Forces Command, New Orleans, Louisiana; and:
* Navy Personnel Command, Millington, Tennessee.
Marine Corps:
* U.S. Marine Corps Health Services, Headquarters;
* U.S. Marine Corps Manpower and Reserve Affairs, Headquarters,
Quantico, Virginia; and:
* Marine Forces Reserve, Headquarters, New Orleans, Louisiana.
Air Force:
* Department of the Air Force, Headquarters;
* Assistant Secretary of the Air Force for Manpower and Reserve
Affairs;
* Office of Air Force Reserve, Headquarters;
* Air Force Reserve Command, Robins Air Force Base, Georgia;
* National Guard Bureau;
* Air National Guard, Headquarters;
* Air National Guard Readiness Center; and:
* Air Reserve Personnel Center, Denver, Colorado.
We also conducted medical and physical fitness file reviews with an
Army National Guard unit from the Mid-Atlantic region and an Army
Reserve unit from the Mid-west region. We chose units that had deployed
for Operations Enduring Freedom or Iraqi Freedom. During these visits
we collected and analyzed information from available[Footnote 62]
medical and personnel files to assess the reserve component members'
compliance with routine medical and physical fitness examinations. We
also documented difficulties the units had in ensuring that all members
complied with medical and physical fitness examinations. Finally,
during the site visits, we conducted group discussions with unit
members regarding their experience with routine examination
requirements.
To gain a better understanding of how the components collect data about
their members' compliance with routine medical and dental examinations
and physical fitness assessments, we assessed the reliability of data
produced by several services' databases. Assessing the reliability of
the services' data included consideration of issues such as the
completeness and currency of the data from the respective database
system's program managers, administrators, and contractors; assurances
that all members are included and the information is up to date; and
examination of who is using the data and for what purposes, and the
users' assessment of reliability. We also examined whether the data
tracked through the services' systems was subjected to quality control
measures, such as conducting periodic testing of the data against
medical records, to ensure the accuracy and reliability of the data. In
addition, we reviewed existing documentation related to the data
sources and interviewed knowledgeable agency officials about the data.
Overall, the reserve components' data we assessed regarding compliance
with routine medical and dental examinations and fitness assessments
did not accurately reflect the total population of service members, had
limited data quality assurance, and were unreliable for the purposes of
this report; however, we determined that the Navy Reserve's medical
data were sufficiently reliable for our purposes. Data from the Navy
Reserve's Medical Readiness Reporting System were found reliable
because Readiness Commands conduct inspections that include examining
the data for accuracy, Medical Department Representatives verify 10
percent of the updated medical records after each weekend drill, and
the data are reported to the Commander, Navy Reserve Forces Command
biweekly. Further, we did not assess the reliability of the Marine
Corps Reserve's medical data because the Marine Corps was in the
process of changing from the Shipboard Automated Medical System, a
stand-alone non-Web-based system, to the Navy Reserve's system. All
reserve components' physical fitness data that we reviewed had missing
or incomplete information, had limited data quality controls, or did
not accurately reflect the total population of service members due to
limited access to the database. Therefore, we determined the data to be
unreliable for the purposes of assisting us in determining reserve
component members' compliance with physical fitness examinations.
To assess DOD's visibility over reserve components' health status after
they are called to duty and the care, if any, provided to those
deployed with preexisting conditions, we collected and analyzed
information from a variety of sources throughout DOD. We interviewed
officials at the six reserve component headquarters and officials
responsible for mobilizing the reserve components. We also observed the
mobilization of Army National Guard and Army Reserve members at Fort
Bliss, Texas, to obtain information on their health status during this
process. We obtained and analyzed data provided on medical
deployability from the DOD-wide centralized database on pre-and
postdeployment health assessments, maintained at the Army Medical
Surveillance Activity, and discussed available data with these
officials. We also obtained and analyzed data on Army servicemembers
who were held at mobilization stations for medical reasons from the
Army's medical holdover database (Medical Operational Data System).
Based on our review of databases we used, we determined that the DOD-
provided data were reliable for the purposes of this report. To address
the extent of medical care provided in theater for preexisting medical
conditions, we reviewed the Joint Chiefs of Staff procedures for
Deployment Health Surveillance and Readiness and information provided
by the U.S. Central Command Surgeon's General office regarding medical
deployment criteria for Operations Enduring Freedom and Iraqi Freedom.
We also collected and reviewed the services' medical instructions,
memoranda, policies, and medical data. We reviewed several databases
for relevance regarding collecting in theater medical data on
preexisting conditions. Specifically, we obtained information and
discussed the following databases: Joint Medical Workstation, the U.S.
Transportation Command Regulating Command and Control Evacuation
System, the Joint Patient Tracking Application, and the Air Force
Institute for Operational Health Disease Nonbattle Injury database.
However, we did not identify any databases used to collect information
on members that may have had preexisting conditions when deployed. We
also interviewed military medical officials who had served in theater
to obtain information on preexisting conditions of reserve component
members while deployed. In addition to those offices and commands
previously listed, we discussed reserve component medical deployment
policies, medical and physical fitness policies and instructions, and
data regarding medical and physical fitness issues with responsible
officials from:
Department of Defense:
* Joint Chiefs of Staff, J-4 (Logistics), Medical Readiness Division;
* U.S. Transportation Command, Scott AFB, Illinois;
* U.S. Central Command, MacDill, AFB, Florida; and:
* Army Medical Surveillance Activity.
Army:
* U.S. Army Office of the Surgeon General and Commanding General, Army
Medical Command;
* U.S. Army Center for Health Promotion and Preventive Medicine-Europe;
* Army Reserve Unit, Mid-west region;
* Walter Reed Army Medical Center; and:
* Soldier Readiness Processing, Medical Operations, Fort Bliss, Texas.
Navy:
* Navy Reserve Readiness Command Southwest, California;
* Navy and Marine Corps Reserve Center, California; and:
* Navy Branch Medical Clinic, Virginia.
Marine Corps:
* Marine Corps Mobilization Command, Kansas City, Missouri; and:
* 4th Combat Engineer Battalion, Maryland.
Air Force:
* Air Force Institute for Operational Health;
* 142nd Fighter Wing Air National Guard, Portland International
Airport, Oregon;
* 163rd Air Refueling Wing Air National Guard, March Air Reserve Base,
California;
* 349th Air Mobility Wing U.S. Air Force Reserve, Travis Air Force
Base, California; and:
* 452nd Air Mobility Wing U.S. Air Force Reserve, March Air Reserve
Base, California.
We reviewed Air Force audit and inspection reports. We interviewed
officials with the Air Force Audit Agency regarding its report on the
Air Force's Individual Deployment Process[Footnote 63] to obtain a
better understanding of the report's scope and methodology to assess
reserve components' compliance with medical and dental requirements. We
assessed the reliability of the Air Force Audit Agency's analyses by
(1) reviewing relevant documentation of their analyses, and (2)
interviewing knowledgeable officials about the audit work and analyses.
We determined the analyses were sufficiently reliable to use as one of
the sources of evidence describing the extent of discrepancies in Air
Force medical and dental records. We also reviewed the Air Force
Inspection Agency's Health Services reports and its annual analysis
reports for calendar year 2004.[Footnote 64]
We also found DOD's Army Medical Surveillance Activity (AMSA) database
and the Army's Medical Operational Data System (MODS) to be
sufficiently reliable for the purposes of our report due to their data
quality controls and currency. In addition, through our review of
existing information about the systems and the resulting data and
through discussions with cognizant agency officials, we found the data
sufficiently reliable for the purposes of this report.
We interviewed the Chief of AMSA. We discussed the information in the
DOD-wide centralized health assessment database and obtained selected
data from all the reserve and active component members' pre-and
postdeployment health assessments that were completed from November
2001 through June 2005. Assessments became mandatory for all mobilized
reserve component members on October 25, 2001. The data we obtained
contained predeployment health assessment records for 383,449 reserve
component members and 627,200 for active members. We analyzed the data
that we obtained to determine the categories of medical referrals and
deployability status.[Footnote 65] We also analyzed data on the self-
reported general health of the reserve component members and compared
the data from predeployment assessments with the data from
postdeployment assessments. All of our analyses compared data across
the reserve components to look for differences or trends.
Further, we reviewed the Army's medical holdover data in MODS and found
them reliable for our reporting purposes. The Office of the Army
Surgeon General uses MODS to monitor and track the medical holdover
population. The intended use of this system is for the MEDCOM and other
command elements to track active and reserve component servicemembers
in outpatient medical treatment, while still on active duty status.
We conducted our review from October 2004 through September 2005 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Comments From the Department of Defense:
ASSISTANT SECRETARY OF DEFENSE:
RESERVE AFFAIRS:
1500 DEFENSE PENTAGON:
WASHINGTON, DC 20301-1500:
OCT 13 2005:
Mr. Derek B. Stewart:
Director, Defense Capabilities and Management:
U.S. Government Accountability Office:
441 G Street, N.W.:
Washington, DC 20548:
Dear Mr. Stewart:
This is the Department of Defense (DoD) response to the GAO draft
report, "MILITARY PERSONNEL: Top Management Attention is Needed to
Address Longstanding Problems with Determining Medical and Physical
Fitness of the Reserve Force", dated September 29, 2005, (GAO Code
350604/GAO-06-105). Written comments to each of the recommendations are
attached.
Should you have any questions reference this response, please direct
them to my point of contact, COL Priscilla Berry, 703-693-8104,
Priscilla.berry@osd.mil:
We appreciate the opportunity to comment on the draft report.
Sincerely,
Signed by:
T. F. Hall:
Attachments: As stated:
GAO DRAFT REPORT - DATED SEPTEMBER 29, 2005 GAO CODE 350604/GAO-06-105:
"MILITARY PERSONNEL: Top Management Attention Is Needed to Address
Longstanding Problems with Determining Medical and Physical Fitness of
the Reserve Force"
DEPARTMENT OF DEFENSE COMMENTS TO THE RECOMMENDATIONS:
RECOMMENDATION 1: The GAO recommended that the Secretary of Defense
direct the Under Secretary of Defense for Personnel and Readiness, in
concert with the Assistant Secretary for Health Affairs, to establish a
management control framework and execute a plan for issuing guidance,
establishing quality assurance for data reliability, and tracking
compliance with routine medical examinations. (Page 66/GAO Draft
Report):
DOD RESPONSE: Non-concur:
The Department of Defense (DoD) remains committed to maximizing its
visibility of medical readiness throughout the Reserve components (RC).
New policies establishing a standardized management framework for a
Force Health Protection Quality Assurance (FHP QA) program, and a
compliance-monitoring program to measure Individual Medical Readiness
(IMR), as called for in this recommendation, are already underway.
Separate Department of Defense Instructions (DODI) establishing
tracking and reporting policies for both programs are in the final
phases of formal coordination. Because these policies, programs, and
instructions are already in place or in process, we do not see the need
for the Secretary of Defense to direct any additional action.
The FHP QA program subsumes and expands upon DoD's Deployment Health QA
program instituted in January 2004. The FHP QA program includes both
DoD and Service level monitoring of electronic data with validation
through medical records reviews of a wide range of force health
protection measures. The IMR program monitors and reports regularly
upon compliance with each of six critical IMR elements and the overall
IMR status for each servicemember, at all levels, from unit to Service
to DoD-wide. The IMR program will improve visibility and enhance
reliability of Reserve component members' health status by replacing
the existing every 5-year physical examination with an annual periodic
health assessment (PHA). The IMR is also being incorporated into
overall unit readiness status reports, providing visibility of RC
medical readiness throughout the line command structure. Many of the
components have already started implementing these program improvements
and are seeing results.
RECOMMENDATION 2: The GAO recommended that the Secretary of Defense
direct the Under Secretary of Defense for Personnel and Readiness, in
concert with the Principal Deputy who oversees the Office of Morale,
Welfare, and Recreation, to take steps to enforce the Service reporting
requirement on the status of their members' physical fitness. (Page
66/GAO Draft Report):
DOD RESPONSE: Concur:
Department of Defense Instruction 1308.3, "DoD Physical Fitness and
Body Fat Programs Procedures," November 5, 2002, which assigns
responsibility to the Principal Deputy Under Secretary of Defense for
Personnel and Readiness (formerly the Assistant Secretary of Defense
for Force Management Policy), requires the DoD Components to: 1)
establish a data repository for their Military Service Physical Fitness
and Body Fat Program; 2) maintain a data repository that provides
initial or baseline statistics and a tracking mechanism that monitors
physical fitness and body fat results as specified in this Instruction;
and 3) provide an annual report to the Under Secretary of Defense
(Personnel and Readiness), not later than March 31, that assesses
Service physical fitness, body fat and health promotion programs. These
first reports were due March 31, 2005. The Air Force, Navy, and Marine
Corps reports have been received.
The Army requested a waiver to this reporting requirement until March
31, 2007, when the Army expects to be able to imbed reporting of this
data within the Defense Integrated Military Human Resources System
(DIMHRS). If reporting through DIMHRS is not on line by September 2006,
the Army agreed to submit a manual report until DIMHRS becomes viable
for reporting this data. The Principal Deputy Under Secretary of
Defense (Personnel and Readiness) approved this request.
The Air Force Surgeon General requested two-year waiver to use
abdominal circumference in lieu of the body fat measurement methodology
described in DoDI 1308.3. The Principal Deputy Under Secretary of
Defense (Personnel and Readiness) approved this request. At the end of
this waiver period, March 31, 2006, the Air Force will provide a
summary of findings and recommendations.
RECOMMENDATION 3: The GAO recommended that the Secretary of Defense
direct the Under Secretary of Defense for Personnel and Readiness, in
concert with the Assistant Secretary for Health Affairs, to also
oversee the development of the reserve components' tracking systems to
identify and track members' temporary and permanent medical conditions
that limit deployability. (Page 66/GAO Draft Report):
DoD RESPONSE: Concur:
The Assistant Secretary of Defense (Health Affairs) (ASD/HA), the
Assistant Secretary of Defense (Reserve Affairs) (ASD/RA), and the
Services are already actively adapting existing systems, and in some
cases creating new ones, that can be used to track the medical status
of Active and Reserve component members, to include those known
conditions that could limit an individual's deployability. Many of
these tools and systems are web-enabled to overcome IM/IT resource
limitations common among RC units and to make it easier for RC members
to provide medical information. Examples of these tools include the
Health Assessment Review Tool (HART, used as part of the annual
periodic health assessment), the DD Form 2900 (Post-deployment Health
Reassessment questionnaire), Medical Protection System (MEDPROS, all
Army components), Preventive Health Assessment and Individual Medical
Readiness (PIMR, Active and Air National Guard), and the Medical
Readiness Review System (MRRS, Navy and Marine Reserve Components). The
DoD continues to pursue better integration between medical and
personnel data systems to improve visibility regarding deployment-
limiting medical conditions, whether temporary or permanent, but the
overall effectiveness will continue to be limited by lack of access to
civilian medical records of Reserve component members.
Problems with the older processes that were meant to ensure medical
readiness have been identified by Joint Forces Command (JFCOM) in its
Lessons Learned Change Recommendation from Operation Iraqi Freedom.
Currently, the Services are addressing these recommendations and are
developing long-term strategic plans to improve RC medical readiness,
to include making appropriate budgetary changes, as part of the
Department's Comprehensive Medical Readiness Plan. Additionally, a RAND
study to ascertain and describe those standards and systems used by the
RC to track medical and dental readiness and the effectiveness of those
systems is underway (sponsored by ASD/RA).
RECOMMENDATION 4: The GAO recommended that the Secretary of Defense
direct the Under Secretary of Defense for Personnel and Readiness, in
concert with the Assistant Secretary for Health Affairs, to modify the
medical pre-deployment forms to better capture reasons for non-
deployment and medical referrals. (Page 66/GAO Draft Report):
DoD RESPONSE: Non-concur:
The Services are committed to improved reporting compliance which will
enable better tracking of reasons for non-deployment of all members.
The basic objective for the pre-deployment health assessments is, ".. a
quick confirmation and documentation of a service member's health
readiness and to determine if there is a need for a clinical evaluation
before deployment.." as specified in an OSD(HA) 6 October 1998 policy
memo. These forms do not substitute for a complete entry in the medical
record that would include a detailed history, the results of any
pertinent physical examination or ancillary testing (lab, radiography,
etc.), assessment, and plan. The existing Pre-Deployment Health
Assessment Form (DD Form 2795) already includes a list of the most
common referral categories to simplify the documentation process for
the healthcare provider. The data from the forms is captured
electronically and is readily available to monitor for trends in
referral patterns, access to specialty care, timeliness of follow-up,
and eventual diagnoses and outcomes. The Department has focused
primarily on this type of analysis in the post-deployment setting. With
the new requirement for annual health assessments across the total
force, the need for a second, equally detailed, assessment as part of
the pre-deployment health assessment process is unnecessarily
disruptive to the deployment process.
Self-reporting tools like the DD Form 2795 are living documents. To
ensure consistency and validity, these documents undergo periodic
review and evidence-based revision. The best sources of accurate
information about what medical reasons kept service members from
deploying are the permanent medical records. Without civilian medical
records to aid in our insight, the annual assessments of Reserve
component members become critically important.
RECOMMENDATION 5: The GAO recommended that the Secretary of Defense
direct the Chairman of the Joint Chief of Staff to determine what pre-
existing medical conditions should not be allowed into specific
theaters of operations, especially during the initial stages of the
operation, and to take steps to ensure that each Service Component
consistently utilizes these as criteria for determining the medical
deployability of its reserve component members during mobilization.
(Page 67/GAO Draft Report):
DoD RESPONSE: Partially Concur:
Clearly, certain pre-existing conditions should render a member non-
deployable to austere theaters of operations where appropriate medical
care is not readily available. The Services, especially the Army, have
made strides in defining these conditions and incorporating them into
their applicable policies and procedures. However, due to the ever-
changing nature of a theater of operations and the inexact nature of
medicine, a list of non-deployable pre-existing conditions will never
be fully comprehensive or fully enforceable. As it is today, a
commander will always have to make a decision regarding the
deployability of each individual service member within their command,
based upon the recommendation of the medical community, their knowledge
of the conditions that will be encountered in theater, and the unique
aspects of the individual's situation.
RECOMMENDATION 6: The GAO recommended that the Secretary of Defense
direct the Chairman of the Joint Chief of Staff, in concert with the
Service Secretaries, to explore using existing tracking systems to
track those who have treatable pre-existing medical conditions in
theater. (Page 67/GAO Draft Report):
DoD RESPONSE: Concur:
Refinements to medical tracking systems are on-going, utilizing lessons-
learned with systems currently in place. Improvements in the
documentation of medical conditions throughout the full continuum of
military service, both active and reserve, will lead to better tracking
and documentation of conditions that affect the health status of all
military members.
COMMENTS NOT RELATED TO RECOMMENDATIONS:
Tracking compliance with routine medical examinations through
electronic databases that contain reliable data is an important task
for both the Active and the Reserve components, as both are held to the
same standards of fitness and medical readiness. While, by design, this
report did not focus on the health status of the Active forces, it is
important to note that both Reserve and Active forces use many of the
same reporting tools within each Service and face the same basic
challenges in ensuring data quality. In situations where tracking
systems are shared, the RC is typically dependent upon the Active
component (AC) to develop and fund these systems. Priority for
deployment of large systems, such as CHCSII, has historically been
given to the AC. The RC has therefore been faced with developing
component-specific programs or trying to accommodate data on their
members in these department-wide systems.
The GAO report indicates that the health status of members deteriorates
with multiple deployments. This is based upon answers provided by
members on their pre-deployment and post-deployment health assessments.
That assumption was not validated with evaluations conducted by health
care providers. It is understandable that members would report a
decline in their overall health status immediately after deployment due
to the multiple physical stressors and rigors of combat experienced
during their time in a theater of operations. However, a study to
determine if their perception of health status improves with time after
returning from deployment has not been done. Thus, such assumptions
should be taken with great caution and in the proper context.
Differences in compliance between the Services often have to do with
the geographically dispersed locations of their RC units. For example,
Air Force RC medical units are typically located in the same location
as the line units, thus giving them the ability to interact directly.
Conversely, Army RC units are geographically dispersed, making it
difficult for medical units to interact directly with non-medical
units. In addition, the Air Force typically utilizes home-station
mobilization, which means that the medical personnel conducting pre-
deployment screenings are more likely to know the members they are
screening and that the medical and command personnel have a greater
opportunity to interact.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Derek B. Stewart (202) 512-5559 or stewartd@gao.gov:
Acknowledgments:
In addition to the contact named above, Brenda S. Farrell, Assistant
Director; James Bancroft, Larry Bridges, Renee S. Brown, Sara Hackley,
Kenya Jones, Ron La Due Lake, Karen Kemper, Julia Matta, Jen Popovic,
and Nicole Volchko.
[End of section]
Related GAO Products:
Defense Health Care: Improvements Needed in Occupational and
Environmental Health Surveillance during Deployment to Address
Immediate and Longstanding Health Issues. GAO-05-632. Washington, D.C.:
July 19, 2005.
Reserve Forces: An Integrated Plan is Needed to Address Army Reserve
Personnel and Equipment Shortages. GAO-05-660. Washington, D.C.: July
12, 2005.
Defense Health Care: Force Health Protection and Surveillance Policy
Compliance Was Mixed, but Appears Better for Recent Deployments. GAO-
05-120. Washington, D.C.: November 12, 2004.
Military Personnel: DOD Needs to Address Long-term Reserve Force
Availability and Related Mobilization and Demobilization Issues. GAO-
04-1031. Washington, D.C.: September 15, 2004.
Defense Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16,
2003.
Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance. GAO-03-1041. Washington, D.C.:
September 19, 2003.
Military Personnel: DOD Needs More Data to Address Financial and Health
Care Issues Affecting Reservists. GAO-03-1004. Washington, D.C.:
September 10, 2003.
Military Personnel: DOD Actions Needed to Improve the Efficiency of
Mobilizations for Reserve Forces. GAO-03-921. Washington, D.C.: August
21, 2003.
Defense Health Care: Army Has Not Consistently Assessed the Health
Status of Early-Deploying Reservists. GAO-03-997T. Washington, D.C.:
July 9, 2003.
Defense Health Care: Army Needs to Assess the Health Status of All
Early-Deploying Reservists. GAO-03-437. Washington, D.C.: April 15,
2003.
Defense Health Care: Most Reservists Have Civilian Health Coverage but
More Assistance Is Needed When TRICARE is Used. GAO-02-829. Washington,
D.C.: September 6, 2002.
VA and Defense Health Care: Military Medical Surveillance Policies in
Place, but Implementation Challenges Remain. GAO-02-478T. Washington,
D.C.: February 27, 2002.
Gender Issues: Improved Guidance and Oversight Are Needed to Ensure
Validity and Equity of Fitness Standards. GAO/NSIAD-99-9. Washington,
D.C.: November 17, 1998.
Defense Health Care: Medical Surveillance Improved Since Gulf War, but
Mixed Results in Bosnia. GAO/NSIAD-97-136. Washington, D.C.: May 13,
1997.
Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet Medical
and Physical Fitness Standards. GAO/NSIAD-94-36. Washington, D.C.:
March 23, 1994.
Operation Desert Storm: War Highlights Need to Address Problem of
Nondeployable Personnel. GAO/NSIAD-92-208. Washington, D.C.: August 31,
1992.
Operation Desert Storm: Full Army Medical Capability Not Achieved.
GAO/NSIAD-92-175. Washington, D.C.: August 18, 1992.
National Guard: Peacetime Training Did Not Adequately Prepare Combat
Brigades for Gulf War. GAO/NSIAD-91-263. Washington, D.C.: September
24, 1991.
FOOTNOTES
[1] DOD's reserve components include the collective forces of the
National Guard including the Army Guard and the Air Guard, as well as
the forces from the Army Reserve, the Navy Reserve, the Marine Corps
Reserve, the Air Force Reserve, and the Coast Guard Reserve. This
report does not address the Coast Guard Reserve.
[2] For the purposes of this report, medical fitness equates to
compliance with routine or periodic medical (physical) examinations
that identify the diseases and medical conditions that may prevent
members from performing their military duties. Physical fitness equates
to compliance with routine or periodic examinations that test a
member's physical skills needed to perform the mission.
[3] Deployment is a troop movement resulting from a Joint Chiefs of
Staff and Unified Command Deployment Order for 30 continuous days or
greater to a land-based location outside the United States.
[4] Operation Enduring Freedom includes ongoing operations in
Afghanistan and in certain other countries; Operation Iraqi Freedom
includes ongoing operations in Iraq.
[5] 10 U.S.C. § 1074f.
[6] 10 U.S.C. § 10102.
[7] Minimal Standards of Fitness for Deployment to the CENTCOM Area of
Responsibility, January 2005.
[8] The Selected Reserve's members include individual mobilization
augmentees--individuals who train regularly, for pay, with active
component units--as well as members who participate in regular training
as members of National Guard or Reserve units.
[9] Mobilization is the process of assembling and organizing personnel
and equipment, activating or federalizing units and members of the
National Guard or Reserves for active duty, and bringing the armed
forces to a state of readiness for war or other national emergency.
[10] 10 U.S.C. § 10206(a).
[11] Prior to 2002, this statute applied to members of the Individual
Ready Reserve and Inactive National Guard as well. Currently, the law
requires that the Individual Ready Reserve be examined as to their
medical fitness as a condition of military duty or promotion, or
attendance at a military school or other career-related action. 10
U.S.C. § 10206(b).
[12] Most reserve members who were called to active duty for other than
normal training after September 11, 2001, were mobilized under one of
three legislative authorities: 10 U.S.C. § 12304, 12302, 12301(d).
[13] Special Assessment of Operations Desert Shield/Storm Mobilization,
Department of the Army, Inspector General, December 1991.
[14] GAO, National Guard: Peacetime Training Did Not Adequately Prepare
Combat Brigades for the Gulf War, GAO/NSIAD-91-263 (Washington, D.C.:
Sept. 24, 1991).
[15] GAO, Operation Desert Storm: Full Army Medical Capability Not
Achieved, GAO/NSIAD-92-175 (Washington, D.C.: Aug. 18, 1992).
[16] Sixth U.S. Army Inspector General Nondeployable Soldiers Special
Inspection, August 1992.
[17] GAO, Reserve Forces: DOD Policies Do Not Ensure That Personnel
Meet Medical and Physical Fitness Standards, GAO/NSIAD-94-36
(Washington, D.C.: Mar. 23, 1994).
[18] AMSA operates the Defense Medical Surveillance System, which was
established in 1997.
[19] GAO, Defense Health Care: Quality Assurance Process Needed to
Improve Force Health Protection and Surveillance, GAO-03-1041
(Washington, D.C.: Sept. 19, 2003).
[20] GAO, Military Personnel: DOD Needs to Address Long-term Reserve
Force Availability and Related Mobilization and Demobilization Issues,
GAO-04-1031 (Washington D.C.: Sept. 15, 2004).
[21] The mandate directed that the Secretary establish the committee
120 days after passage of the act, which was in October 2004.
[22] OSD's Office of Health Affairs has begun a process requiring each
active and reserve component to quarterly report the percentage of its
members who are in compliance with six medical readiness elements: (1)
dental class I or II; (2) immunizations; (3) medical readiness
laboratory tests, such as DNA blood sample; (4) no deployment-limiting
conditions; (5) periodic health assessment; and (6) medical equipment,
such as eyeglass inserts for gas masks.
[23] 10 U.S.C. § 10206 states that "each member of the Selected Reserve
who is not on active duty shall be examined as to his physical fitness
every five years, or more often as the Secretary concerned considers
necessary." In 1993, the interval was changed from every 4 years to
every 5 years.
[24] In 2003, DOD asked the Armed Forces Epidemiological Board to
review the appropriate methodology and interval for routine medical
examinations to be applied similarly across all services. Based on the
board's recommendations, the Assistant Secretary of Defense for Health
Affairs is currently drafting a policy that would replace the 5-year
medical examination with an annual periodic health assessment. Congress
is currently considering changing the frequency requirement for a
physical examination from every 5 years to annually as part of the 2006
national defense authorization act.
[25] In 1993, Congress mandated that these examinations be conducted at
least once every 5 years. Prior to 1993, the requirement was once every
4 years.
[26] Members are given a (PUHLES) physical capacity or stamina, upper
extremities, hearing, lower extremities, eyes, psychiatric score of 1
to 4 for each of the six assessment areas. P1 represents a nonduty-
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 servicemember in a nondeployable status or
may result in the changing of the reserve component member's job
classification.
[27] The Air Force Reserve and Air National Guard discontinued
utilizing the "complete or comprehensive" long physical exams in July
2001 and January 2003, respectively. However, annual physical exams for
flying personnel continue to be conducted in both components.
[28] A PHAM is a credentialed health care provider, and may be a
physician, nurse practitioner, or physician's assistant. A PHAM
performing examinations for flying personnel must be a flight surgeon.
[29] An HCP is a credentialed health care provider, and may be a
physician, nurse practitioner, or physician's assistant. An HCP
performing flying personnel examinations must be a flight surgeon.
[30] 10 U.S.C. § 10206(a)(2).
[31] On December 19, 1996, the Assistant Secretary of Defense for
Health Affairs issued DOD policy in Health Affairs Memo 97-020,
standardizing dental classifications: Class I indicates no dental
treatment or reevaluation required within the next 12 months; Class II
indicates patients have the potential for dental emergencies with the
next 12 months but it is not likely if certain treatments are obtained;
Class III represents patients with oral conditions that if not treated
are expected to result in dental emergencies within the next 12 months;
and Class IV represents patients requiring a dental examination and
whose dental classification is unknown.
[32] On February 19, 1998, the Assistant Secretary of Defense for
Health Affairs issued DOD policy, in Health Affairs Memo 98-021,
requiring annual dental examinations and stipulating that personnel
shall not deploy in Dental Class III or IV except under extreme
circumstances.
[33] While Army regulation, AR 40-501, only addresses an annual dental
examination for the Army National Guard, according to the Army Dental
Command and the Army Reserve, Army Reserve members adhere to the same
dental standard.
[34] The dental screening was more limited than the current dental
examination. It included a mouth-mirror, and explorer or tongue
depressor evaluation only.
[35] DOD Directive 1308.1, "DOD Physical Fitness and Body Fat Program".
[36] GAO, Reserve Forces: DOD Policies Do Not Ensure That Personnel
Meet Medical and Physical Fitness Standards, GAO/NSIAD-94-36
(Washington, D.C.: Mar. 23, 1994).
[37] The Assistant Secretary of Defense for Health Affairs is currently
drafting a policy intended to help standardize implementation of the
medical examination requirements.
[38] GAO, Reserve Forces: DOD Policies Do Not Ensure That Personnel
Meet Medical and Physical Fitness Standards, GAO/NSIAD-94-36
(Washington, D.C.: Mar. 23, 1994).
[39] DOD Directive 1308.1.
[40] GAO, Gender Issues: Improved Guidance and Oversight Are Needed to
Ensure Validity and Equity of Fitness Standards, GAO/NSIAD-99-9
(Washington, D.C.: Nov. 17, 1998).
[41] This position was referred to as the Assistant Secretary of
Defense (Force Management Policy) at the time the directive was revised
in 2002.
[42] Over 1,400 active and reserve component leaders, soldiers, and
civilians in 35 locations in the United States were contacted by the
Army Inspector General during its review.
[43] We are 90 percent confident that the true percentage of medical
discrepancies is within +/-6.1 percentage points of our estimate.
[44] Department of the Army Inspector General Special Inspection of
Army Mobilization/Demobilization in Support of Recent and Ongoing
Operations, November 2003-June 2004, February 28, 2005.
[45] We are 90 percent confident that the true percentage of medical
discrepancies is within +/-6.1 percentage points of our estimate.
[46] At the time of our review, 110 members did not have an APFT on
file. In addition, there were service members who did not take a
physical fitness test for the record during 2005, nor did they have a
temporary or permanent profile when completing the physical fitness
test.
[47] GAO, Reserve Forces: DOD Policies Do Not Ensure That Personnel
Meet Medical and Physical Fitness Standards, GAO/NSIAD-94-36
(Washington, D.C.: Mar. 23, 1994).
[48] GAO-04-1031.
[49] This program was established following our 2003 review, GAO,
Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance, GAO-03-1041 (Washington, D.C.:
Sept. 19, 2003).
[50] Draft regulation for the Medical Holdover Case Management Program
states that a case manager is normally a registered nurse who is
assigned to manage the medical care provided each medical holdover
soldier. The case manager implements the case management process with a
focus on clinical evaluation and outcomes.
[51] As of August 11, 2005, the total number in medical holdover was
4,866--860 of whom were placed there prior to deployment, and the
remainder of whom were placed there due to a medical condition
developed during deployment.
[52] According to an Army official, 87 of these 860 have been in a
medical holdover status for over a year due to complex medical
conditions, such as cancer.
[53] Conditions that could disqualify a reserve component servicemember
from deployment and would cause the member to be released if identified
medically nondeployable during the first 25 days of activation include
temporary and permanent conditions that do not meet medical deployment
standards as outlined in AR 40-501, Chapter 3.
[54] For the purposes of this report, preexisting medical conditions
refer to those medical conditions that were not identified during
mobilization that may limit a member's ability to perform his or her
mission and cannot be adequately addressed in theater.
[55] Minimal Standards of Fitness for Deployment to the CENTCOM Area of
Responsibility, January 2005.
[56] Army Regulation 40-501 was updated to include standards for
deployment in February 2005.
[57] Although some systems exist to track various aspects of medical
care provided in theater, we did not identify any system that tracks
care provided to reserve component members for preexisting conditions.
[58] This is based on Dental Class III or IV classification standards.
This is a servicewide standard.
[59] The Air National Guard issued the memorandum, via SG Log Letter 04-
026, on September 27, 2004.
[60] From November 2003 through January 2004, the reservist incurred a
total of 20 dental office and clinic visits and received two fillings,
two extractions, four root canals, and three crowns, at a cost of about
$5,200 to the military.
[61] Unless otherwise noted, the officials listed in this appendix have
their offices in the Pentagon or at locations in the Washington, D.C.,
metropolitan area.
[62] We reviewed all available medical and physical fitness files
during our visits to the units. Some files were not available because
(1) members who had deployed with the unit had transferred to another
unit or were no longer serving, (2) some files had been misplaced, and
(3) some members were having a routine exam and their file was with
them.
[63] Air Force Audit Agency, Individual Deployment Process, Audit
Report F2005-0005-FD3000 (June 13, 2005).
[64] Air Force Inspection Agency, Health Services Inspection, ARC
Inspection Results, ARC Element Results, Annual Analysis Calendar Year
2004 (as of June 20, 2005).
[65] The data represent deployment events. A deployment event is
defined as a servicemember completing a pre-or postdeployment health
assessment form with no recent history (within 6 months) of completing
a separate pre-or postdeployment health assessment form.
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