Defense Health Care
DOD has Established a Chiropractic Benefit for Active Duty Personnel Gao ID: GAO-05-890R September 6, 2005The Floyd D. Spence National Defense Authorization Act for Fiscal Year 2001 (NDAA 2001) directed the Department of Defense (DOD) to develop and implement a plan to make a chiropractic benefit available to all active duty personnel in the U.S. armed forces. The practice of chiropractic focuses on the relationship between structure (primarily, the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health. In August 2001, DOD submitted to Congress an implementation plan that described how it planned to develop a chiropractic benefit within the military health system. The plan addressed patient eligibility, access to care, the location of chiropractic clinics, projected costs, staffing, and the marketing and monitoring of the benefit. The NDAA 2001 directed DOD to develop the implementation plan in consultation with the Oversight Advisory Committee (OAC), which was established by the National Defense Authorization Act for Fiscal Year 1995 (NDAA 1995). The OAC was directed by the NDAA 1995 to oversee a 3-year DOD chiropractic demonstration project at no fewer than 10 military treatment facilities (MTF). The NDAA 1995 directed that the OAC include the Assistant Secretary of Defense for Health Affairs; the Surgeons General of the Army, the Air Force, and the Navy; and at least four representatives of the chiropractic profession; and also directed that we serve as a member of the OAC. As a member of the OAC, we attended meetings of the OAC and provided technical input and advice. The NDAA 2001 also mandated that we monitor the development and implementation of DOD's chiropractic health care plan. As agreed with the committees of jurisdiction, we reviewed the implementation of DOD's chiropractic benefit.
To implement its chiropractic benefit, DOD has opened chiropractic clinics at 42 of its 238 MTFs, worldwide, and does not plan to add any additional clinics at this time. All of DOD's 1.8 million active-duty personnel are eligible for the benefit. The 42 chiropractic clinics are located in the United States in areas with a high number of active-duty personnel. Approximately 969,000, or 54 percent, of active-duty personnel reside in the areas served by the MTFs with chiropractic clinics. To support the benefit, DOD provides annual allotments from its health care budget. In fiscal year 2004, the allotment increased to $11 million. An additional $203,000 was provided by the MTFs with chiropractic clinics in fiscal year 2004. DOD generally adhered to the priorities specified in its implementation plan in selecting the sites for the 42 clinics and in determining the clinics' staffing levels. DOD has not completed other actions described in the implementation plan. For example, DOD's implementation plan stated that a marketing and promotion program, which would include pamphlets and other materials, would be necessary to make active-duty personnel aware of the benefit. However, DOD did not provide active-duty personnel with such materials as specified in the plan. Instead, DOD relied on each MTF to determine whether and how to promote the benefit. The implementation plan also called for close monitoring of the benefit to determine whether the benefit meets current needs, but DOD officials said that they had not monitored whether the benefit meets current or future demand from active-duty personnel.
GAO-05-890R, Defense Health Care: DOD has Established a Chiropractic Benefit for Active Duty Personnel
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September 6, 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:
Subject: Defense Health Care: DOD Has Established a Chiropractic
Benefit for Active Duty Personnel:
The Floyd D. Spence National Defense Authorization Act for Fiscal Year
2001 (NDAA 2001) directed the Department of Defense (DOD) to develop
and implement a plan to make a chiropractic benefit available to all
active duty personnel in the U.S. armed forces.[Footnote 1] The
practice of chiropractic focuses on the relationship between structure
(primarily, the spine) and function (as coordinated by the nervous
system) and how that relationship affects the preservation and
restoration of health. In August 2001, DOD submitted to Congress an
implementation plan that described how it planned to develop a
chiropractic benefit within the military health system. The plan
addressed patient eligibility, access to care, the location of
chiropractic clinics, projected costs, staffing, and the marketing and
monitoring of the benefit.
The NDAA 2001 directed DOD to develop the implementation plan in
consultation with the Oversight Advisory Committee (OAC), which was
established by the National Defense Authorization Act for Fiscal Year
1995 (NDAA 1995). The OAC was directed by the NDAA 1995 to oversee a 3-
year DOD chiropractic demonstration project at no fewer than 10
military treatment facilities (MTF).[Footnote 2] The NDAA 1995 directed
that the OAC include the Assistant Secretary of Defense for Health
Affairs; the Surgeons General of the Army, the Air Force, and the Navy;
and at least four representatives of the chiropractic profession; and
also directed that we serve as a member of the OAC.[Footnote 3] As a
member of the OAC, we attended meetings of the OAC and provided
technical input and advice.
The NDAA 2001 also mandated that we monitor the development and
implementation of DOD's chiropractic health care plan. As agreed with
the committees of jurisdiction, we reviewed the implementation of DOD's
chiropractic benefit.[Footnote 4]
To review the implementation of DOD's chiropractic benefit, we examined
relevant legislation, statutes, and reports containing congressional
directives to DOD for establishing and enhancing the chiropractic
benefit as well as those directing earlier chiropractic demonstration
projects. We reviewed DOD's February 2000 Final Chiropractic Health
Care Demonstration Program Report and DOD's August 2001 Report on
Chiropractic Health Care Implementation Plan (implementation plan). We
also reviewed pertinent DOD policies and procedures, and communications
between the services and the TRICARE Management Activity (TMA), the
office responsible for ensuring that DOD's health policy is
implemented. We collected workload, staffing, and financial data from
fiscal year 2002 through fiscal 2004 from each of the MTFs that have
established chiropractic clinics. Although we did not independently
verify the data that we collected, we queried representatives from each
of the services to review the systems used for collecting and
maintaining the data. We determined that the data were adequate for our
purpose. We interviewed officials from the TMA, the Offices of the
Surgeons General of the Air Force, Army, and Navy; and officials and
chiropractors from five MTFs that have chiropractic clinics. We also
interviewed an official from Cherokee Nation, a company that contracts
chiropractors to work in chiropractic clinics for the Army and Air
Force. We conducted our review according to generally accepted
government auditing standards from October 2004 through August 2005.
Results in Brief:
To implement its chiropractic benefit, DOD has opened chiropractic
clinics at 42 of its 238 MTFs, worldwide, and does not plan to add any
additional clinics at this time. All of DOD's 1.8 million active-duty
personnel are eligible for the benefit. The 42 chiropractic clinics are
located in the United States in areas with a high number of active-duty
personnel. Approximately 969,000, or 54 percent, of active-duty
personnel reside in the areas served by the MTFs with chiropractic
clinics. To support the benefit, DOD provides annual allotments from
its health care budget. In fiscal year 2004, the allotment increased to
$11 million. An additional $203,000 was provided by the MTFs with
chiropractic clinics in fiscal year 2004. DOD generally adhered to the
priorities specified in its implementation plan in selecting the sites
for the 42 clinics and in determining the clinics' staffing levels. DOD
has not completed other actions described in the implementation plan.
For example, DOD's implementation plan stated that a marketing and
promotion program, which would include pamphlets and other materials,
would be necessary to make active-duty personnel aware of the benefit.
However, DOD did not provide active- duty personnel with such materials
as specified in the plan. Instead, DOD relied on each MTF to determine
whether and how to promote the benefit. The implementation plan also
called for close monitoring of the benefit to determine whether the
benefit meets current needs, but DOD officials said that they had not
monitored whether the benefit meets current or future demand from
active-duty personnel.
In commenting on a draft of this report, DOD generally agreed with our
findings. DOD noted that oversight of the chiropractic clinics is
provided at the service level, which involves frequent communication
with TMA regarding medical care, budget, and legislative issues that
affect the chiropractic program across the military health system.
Background:
Military health care is provided by TRICARE, DOD's health provider
network. TRICARE covers about 9.1 million beneficiaries, including
active-duty and retired members of the armed services and their
families. The military health system's primary mission is to maintain
the health of 1.8 million military personnel engaged in active
duty.[Footnote 5] Costing about $17.8 billion in fiscal year 2004,
TRICARE is financed through DOD's Defense Health Program (DHP) budget.
The services administer TRICARE through their respective MTFs and other
providers. Worldwide, DOD has 238 MTFs. The Surgeon General of each
service has authority over the MTFs for that branch of the service.
Congress has directed that DOD consider implementing a chiropractic
benefit in the military health system since the 1980s. The Department
of Defense Authorization Act of 1985 mandated that DOD conduct a
demonstration project to evaluate the cost-effectiveness of
incorporating chiropractic services for active-duty service members,
retirees, and their dependents, as part of the Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS) benefit, the
military health system in place prior to TRICARE.[Footnote 6] In August
1993, DOD prepared a report to Congress on the CHAMPUS Chiropractic
Demonstration Project. The report stated that after a 2-year
demonstration project conducted in two states, DOD did not favor
establishing a permanent benefit because other types of care had higher
priority for the DHP's limited funds.
In the NDAA 1995, Congress directed the Secretary of Defense to
establish another demonstration program at no fewer than 10 sites for 3
years to evaluate the feasibility and advisability of expanding DOD's
health system to include the chiropractic benefit.[Footnote 7] The NDAA
1995 also directed the Secretary to convene the OAC to, among other
things, submit to Congress a plan for evaluating the program. The
Secretary, with assistance from the OAC, was required to produce a
final report at the conclusion of the demonstration period. The
National Defense Authorization Act for Fiscal Year 1998 directed that
the demonstration be increased to include at least three additional
clinics in the MTFs that were not already designated to participate in
the program, and it also extended the program for 2 more years, to
conclude at the end of fiscal year 1999.[Footnote 8]
DOD issued its Final Chiropractic Health Care Demonstration Program
Report in February 2000. The report concluded that it was feasible to
integrate chiropractic care services into DOD's health system because
chiropractic services complemented traditional medical care for
patients with back pain but that it was not advisable to do so because
of the additional costs entailed. The report stated that chiropractic
care posed an additional cost because it did not fully offset the costs
of traditional, nonchiropractic, medical care. DOD estimated that the
anticipated total cost of making chiropractic care available to all
TRICARE beneficiaries could reach $70 million annually.[Footnote 9] The
report also stated that because of fiscal limitations within the
military health system, full implementation of the chiropractic benefit
would necessitate reducing or eliminating other existing medical
programs.
In the NDAA 2001, Congress directed DOD to develop a plan to provide
the chiropractic benefit for all active-duty members of the
military.[Footnote 10] In August 2001, DOD issued its implementation
plan, which served as an operational framework for DOD in implementing
its chiropractic benefit. Enclosure I lists selected legislation
directed toward establishing and increasing the availability of DOD's
chiropractic benefit.
DOD Has Made the Chiropractic Benefit Available at 42 MTFs in the
United States:
To implement its chiropractic benefit, DOD has opened chiropractic
clinics in 42 of its 238 MTFs. DOD does not currently plan to open
additional clinics, but DOD officials said they continue to assess
additional need for the benefit. The benefit is provided for active-
duty personnel at the MTFs with chiropractic clinics, all of which are
located in the United States. The locations for clinics were selected
because they are in areas that have a high number of active-duty
personnel. Approximately 969,000, or 54 percent, of active-duty
personnel, reside in the areas served by the MTFs with chiropractic
clinics. DOD allocated $11 million to the benefit in fiscal year 2004,
and an additional $203,000 was provided by the MTFs with chiropractic
clinics. DOD generally followed its implementation plan in locating and
staffing its chiropractic clinics, but it did not actively promote or
closely monitor the benefit as described in the plan.
DOD Has Opened Clinics at 42 MTFs and Does Not Plan to Open More:
DOD has opened chiropractic clinics for active-duty members of the
uniformed services at 42 of DOD's 238 MTFs and does not plan to open
additional clinics. The NDAA 2001 mandated that DOD create a plan to
fully implement the chiropractic benefit; DOD responded by developing
and submitting an implementation plan in August 2001 and began
implementing the program in October of that same year. By fiscal year
2003, DOD had opened 31 chiropractic clinics. In a committee report for
the National Defense Authorization Act for Fiscal Year 2004, the Senate
Committee on Armed Services directed that DOD provide the benefit at no
fewer than 45 sites by the end of fiscal year 2004.[Footnote 11] DOD
officials said they have fulfilled the requirements of the law and do
not have immediate plans to add any additional clinics. They also said
they will continue to assess additional need for the benefit.
The chiropractic clinics have been opened at the MTFs in the United
States with large active-duty populations. As of June 2005, the Army
had opened the most chiropractic clinics with 17, the Air Force had
opened 14, and the Navy had opened 11. Each of the 42 chiropractic
clinics accepts active-duty patients from the other services. Figure 1
shows the locations of the MTFs that have chiropractic
clinics.[Footnote 12]
Figure 1: Location of DOD's 42 Chiropractic Clinics (August 2005):
[See PDF for image]
Note: Specific locations are listed in enc. II.
[End of figure]
Fifty-Four Percent of Active-Duty Personnel Are Served by the MTFs with
Chiropractic Clinics:
Approximately 969,000, or 54 percent, of active-duty personnel, reside
in the areas served by the MTFs with chiropractic clinics. (See table
1.) However, DOD officials said that the chiropractic benefit is
available to all active-duty personnel because they can be referred by
their primary care manager to a chiropractor located in one of DOD's 42
chiropractic clinics. DOD officials said that personnel residing in
remote and overseas locations or in locations that are not near an MTF
with a chiropractic clinic can travel, if necessary, to receive the
benefit. According to DOD data, 19 percent of active-duty personnel
currently reside in remote or overseas areas. DOD defines a remote area
as an area in the United States in which an active-duty member resides
and works more than 50 miles from an MTF. An additional 28 percent of
active-duty personnel reside in areas of the U.S. served by MTFs that
do not have chiropractic clinics. Currently, there is no provision for
active-duty personnel to receive chiropractic services in the civilian
or purchased-care sector.
Table 1: Proximity of Active Duty Personnel to Chiropractic Clinics
(August 2005):
Location of active-duty personnel: Residing in areas served by a
chiropractic clinic;
Active-duty population: 969,000;
Percent of active-duty population: 54%.
Location of active-duty personnel: Residing in locations not served by
a chiropractic clinic: Living overseas;
Active-duty population: 246,000;
Percent of active-duty population: 14%.
Location of active-duty personnel: Residing in locations not served by
a chiropractic clinic: Living in remote areas;
Active-duty population: 88,000;
Percent of active-duty population: 5%.
Location of active-duty personnel: Residing in locations not served by
a chiropractic clinic: Living in areas of the United States served by
MTFs with no chiropractic clinic;
Active-duty population: 497,000;
Percent of active-duty population: 28%.
Location of active-duty personnel: Residing in locations not served by
a chiropractic clinic: Total;
Active-duty population: 831,000;
Percent of active-duty population: 46%.
Location of active-duty personnel: Total;
Active-duty population: 1,800,000;
Percent of active-duty population: 100%.
Sources: TMA and the Offices of the Surgeons General of the Air Force,
Army, and Navy, DOD.
[End of table]
DOD's Allotments for the Benefit Have Increased:
Since 2002 the chiropractic benefit has been directly funded from the
DHP with an annual allotment for each of the services. DOD's annual
allotment to the chiropractic benefit has grown over time to $11
million in fiscal year 2004. Table 2 shows the annual DHP allotments
for the chiropractic benefit for fiscal years 2002 through 2004 as well
as the number of clinics in operation by each service for the same
period.
Table 2: Annual DHP Allotments Directly for the Chiropractic Program
and Number of Clinics, by Service, Fiscal Years 2002-2004:
Dollars in millions.
Service: Air Force;
Fiscal year 2002: DHP allotment: $1.80;
Fiscal year 2002: Number of clinics: 4;
Fiscal year 2003: DHP allotment: $1.70;
Fiscal year 2003: Number of clinics: 8;
Fiscal year 2004: DHP allotment: $2.70;
Fiscal year 2004: Number of clinics: 14.
Service: Army;
Fiscal year 2002: DHP allotment: $2.3;
Fiscal year 2002: Number of clinics: 5;
Fiscal year 2003: DHP allotment: $4.4;
Fiscal year 2003: Number of clinics: 13;
Fiscal year 2004: DHP allotment: $4.3;
Fiscal year 2004: Number of clinics: 17.
Service: Navy;
Fiscal year 2002: DHP allotment: $1.8;
Fiscal year 2002: Number of clinics: 5;
Fiscal year 2003: DHP allotment: $3.6;
Fiscal year 2003: Number of clinics: 10;
Fiscal year 2004: DHP allotment: $4;
Fiscal year 2004: Number of clinics: 11.
Total;
Fiscal year 2002: DHP allotment: $6.00;
Fiscal year 2002: Number of clinics: 14;
Fiscal year 2003: DHP allotment: $9.80;
Fiscal year 2003: Number of clinics: 31;
Fiscal year 2004: DHP allotment: $11;
Fiscal year 2004: Number of clinics: 42.
Source: DOD.
Notes: DHP allotments are in millions of dollars. Totals may not add
because of rounding.
[End of table]
Most MTFs provide additional financial support for their respective
chiropractic clinics from their own resources. Twenty-six of the 42
MTFs that have chiropractic clinics have provided additional financial
support from funds that the MTFs have received for their general use to
cover supplies or incidental items. The amount of funding provided by
MTFs for their respective clinics has varied from one MTF to another.
Table 3 shows the amount of MTF funds provided for chiropractic
clinics, as well as the number of clinics in operation, by service for
fiscal years 2002 through 2004.
Table 3: MTF Funds Provided for Chiropractic Clinics and Number of
Clinics, by Service, Fiscal Years 2002-2004:
Service: Air Force;
Fiscal year 2002: MTF funds: $10,571;
Fiscal year 2002: Number of clinics: 4;
Fiscal year 2003: MTF funds: $40,642;
Fiscal year 2003: Number of clinics: 8;
Fiscal year 2004: MTF funds: $94,932;
Fiscal year 2004: Number of clinics: 14.
Service: Army;
Fiscal year 2002: MTF funds: $25,768;
Fiscal year 2002: Number of clinics: 5;
Fiscal year 2003: MTF funds: $54,012;
Fiscal year 2003: Number of clinics: 13;
Fiscal year 2004: MTF funds: $44,222;
Fiscal year 2004: Number of clinics: 17.
Service: Navy;
Fiscal year 2002: MTF funds: $111,317;
Fiscal year 2002: Number of clinics: 5;
Fiscal year 2003: MTF funds: $60,914;
Fiscal year 2003: Number of clinics: 10;
Fiscal year 2004: MTF funds: $63,674;
Fiscal year 2004: Number of clinics: 11.
Total;
Fiscal year 2002: MTF funds: $147,656;
Fiscal year 2002: Number of clinics: 14;
Fiscal year 2003: MTF funds: $155,568;
Fiscal year 2003: Number of clinics: 31;
Fiscal year 2004: MTF funds: $202,828;
Fiscal year 2004: Number of clinics: 42.
Sources: Offices of the Surgeons General of the Air Force, Army, and
Navy.
Note: Funds contributed by MTFs were in addition to the DHP allotments
provided to the services.
[End of table]
DOD Generally Followed Its Implementation Plan in Establishing the
Benefit:
DOD generally followed its implementation plan in selecting sites and
determining staffing levels for the chiropractic clinics that were
opened after the conclusion of the demonstration project but did not
complete other actions described in the implementation plan. In
determining locations for chiropractic clinics, DOD noted in its
implementation plan that chiropractic care would continue at the 13
MTFs that had chiropractic clinics established for the demonstration
project. For each service, the implementation plan included a list of
MTFs considered for receiving chiropractic clinics, prioritized by
projected demand on the basis of the size of the active duty population
served by the MTFs. Decisions about opening chiropractic clinics at
particular MTFs also were based upon criteria reflecting specific
aspects of the areas served by the MTFs. DOD officials said that, in
addition to the criteria used to develop the lists, other factors that
were considered included the (1) proximity of other MTFs offering
chiropractic services, (2) availability of space at the MTF, and (3)
plans for future construction at the MTF. The implementation plan
provided the services with guidance on the order for opening the
clinics. However, DOD gave the services discretion in deciding which
clinics to open on the basis of all of the factors.
The locations of the clinics suggest that DOD generally opened clinics
at the MTFs in the order in which they appear on the list in its
implementation plan. (See enc. II.) The Army opened clinics at 17 of
the first 18 MTFs appearing on the list, the Navy opened clinics at 11
of the first 12, and the Air Force opened clinics at 14 of the first
25. Officials from the Surgeons General's offices said that the lack of
available space at an MTF was the most common reason that an MTF on the
list would not have received a clinic but said that the services
carefully evaluated each site on the list.
DOD officials said they also generally followed the criteria stated in
the implementation plan for staffing the clinics. According to DOD's
implementation plan, staffing levels at each clinic would be based on
the number of active-duty personnel and historical MTF workloads. DOD
assumed that a single chiropractor with one assistant could treat
approximately 1,000 patients and handle 4,200 visits a year from these
patients. At the end of fiscal year 2004, DOD had staffed its 42
clinics with 58 chiropractors. Most of the clinics are staffed with a
single chiropractor. DOD's chiropractors are civilian contractors. The
Army and Air Force use a third-party firm to hire their chiropractic
contractors, while the Navy hires its entire chiropractic staff through
the Navy Medical Logistics Command. Table 4 shows the number of
chiropractors staffed in DOD chiropractic clinics, by service, since
fiscal year 2002.
Table 4: Number of Chiropractors Staffed in DOD Chiropractic Clinics,
by Service, Fiscal Years 2002-2004:
Service: Air Force;
Fiscal Year 2002: 11;
Fiscal Year 2003: 14;
Fiscal Year 2004: 18.
Service: Army;
Fiscal Year 2002: 13;
Fiscal Year 2003: 19;
Fiscal Year 2004: 21.
Service: Navy;
Fiscal Year 2002: 9;
Fiscal Year 2003: 18;
Fiscal Year 2004: 19.
Total;
Fiscal Year 2002: 33;
Fiscal Year 2003: 51;
Fiscal Year 2004: 58.
Sources: Offices of the Surgeons General of the Air Force, Army, and
Navy.
[End of table]
The implementation plan anticipated that staffing requirements would be
recomputed according to demand as the chiropractic program matured and
data were collected to evaluate the benefit. However, DOD has not
conducted a formal assessment of staffing needs since October 2001,
when the benefit was first established. Instead, service
representatives said they have staffed clinics on the basis of input
from the MTFs about how they are handling their workload and said that
they communicate as needed with the MTF officials to assess the status
of the chiropractic clinics and solve any staffing issues that might
arise.
DOD has not completed other actions described in the implementation
plan. For example, DOD's implementation plan stated that a marketing
and promotional program would be necessary to make personnel aware of
the benefit, as well as to inform their physicians, case managers, and
commanders about the benefit. Such a program was to include promotional
materials such as handouts, posters, generic news items for post or
base papers, or other similar materials. However, DOD's promotional
activities have been limited. For example, DOD officials said that DOD
had not provided materials for promoting the chiropractic benefit to
the services but had instead left it to the services to promote the
benefit. Service representatives said that they had not produced
promotional materials about the chiropractic benefit and did not
monitor the MTFs' promotional efforts. The MTF staff we interviewed
said that they had not produced materials to promote the chiropractic
benefit. We found that only 10 of the 42 MTFs with chiropractic clinics
included the chiropractic benefit on their Web site. In addition,
although the implementation plan stated that DOD would monitor the
program to determine whether the benefit meets current needs and to
identify future demand, DOD officials told us that they have not
conducted such monitoring.
Agency Comments:
We requested comments on a draft of this report from DOD. DOD provided
written comments that are reprinted in enclosure III. In its comments,
DOD generally concurred with our findings, noting that oversight of the
chiropractic clinics is provided at the service level, which involves
frequent communication with TMA regarding medical care, budget, and
legislative issues that affect the chiropractic program across the
military health system. We incorporated technical comments provided by
DOD as appropriate.
We are sending copies of this report to the Secretary of Defense,
appropriate congressional committees, and other interested parties.
Copies will also be made available to others upon request. In addition,
this report is available at no charge on GAO's Web site at
http://www.gao.gov. If you or your staff have any questions regarding
this report, please contact me at (202) 512-7101 or crossem@gao.gov.
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. Contributions
were made by Tom Conahan, Assistant Director; Martin Gahart; Cathleen
Hamann, and Carolina Morgan.
Signed by:
Marcia Crosse:
Director, Health Care:
Enclosures - 3:
Enclosure I:
Selected Laws Pertaining to Development of DOD's Chiropractic Benefit:
Law: Department of Defense Authorization Act, 1985, Pub. L. No. 98-525
§ 632(b), 98 Stat. 2492, 2543 (1984);
Description: Directed the Secretary of Defense to conduct demonstration
projects to determine the cost-effectiveness of a chiropractic benefit
for CHAMPUS-eligible beneficiaries.
Law: National Defense Authorization Act for Fiscal Year 1995, Pub. L.
No. 103-337, § 731, 108 Stat. 2663, 2809 (1994);
Description: Required that the Secretary of Defense establish a 3-year
chiropractic demonstration program at no less than 10 military
treatment facilities to evaluate the feasibility and advisability of
providing chiropractic care through the medical care facilities of the
Armed Forces. Provided for establishment of an Oversight Advisory
Committee (OAC) to assist and advise in the development and conduct of
the demonstration program.
Law: National Defense Authorization Act for Fiscal Year 1998, Pub. L.
No. 105-85, § 739(a), (b), 111 Stat. 1629, 1815 (1997);
Description: Extended the demonstration program for 2 years through
fiscal year 1999. Mandated the expansion of the chiropractic health
care demonstration program to at least three additional treatment
facilities.
Law: Floyd D. Spence National Defense Authorization Act for Fiscal Year
2001, Pub. L. No. 106-398, § 702, 114 Stat. 1654, App. A 1654A-173-174
(2000);
Description: Required the development and implementation of a plan to
provide a permanent chiropractic care benefit for all active-duty
personnel to be phased in over a 5-year period, beginning October 1,
2001. Required that GAO monitor the development and implementation of
the chiropractic plan.[A].
Law: National Defense Authorization Act for Fiscal Year 2004, Pub. L.
No. 108-136, § 711, 117 Stat. 1392, 1530 (2003);
Description: Required the Secretary of Defense to accelerate the
implementation of the plan to provide a chiropractic benefit for active-
duty personnel, with the goal of completing the implementation of the
plan by October 1, 2005, rather than the original deadline of October
1, 2006.
Source: GAO.
Note: CHAMPUS = Civilian Health and Medical Program of the Uniformed
Services.
[A] We did not evaluate the development of DOD's implementation plan
because of our previous role as a member of the OAC in accordance with
NDAA 1995. In our role, we participated in developing DOD's
implementation plan by providing the OAC with a member. To maintain
compliance with the independence requirements of generally accepted
government auditing standards, we are unable to evaluate the
development of that same plan.
[End of table]
Enclosure II:
Military Treatment Facilities Considered for Chiropractic Clinics, in
Order of Projected Demand, by Service:
Air Force:
Military treatment facilities as listed in implementation plan: 59th
Medical Wing, Lackland Air Force Base (AFB), Tex.[A];
Date opened: September 1998.
Military treatment facilities as listed in implementation plan: 11th
Medical Group, Bolling AFB, D.C;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 10th
Medical Group, U.S. Air Force Academy, Colo;
Date opened: October 2002.
Military treatment facilities as listed in implementation plan: 1st
Medical Group, Langley AFB, Va;
Date opened: October 2002.
Military treatment facilities as listed in implementation plan: 55th
Medical Group, Offutt AFB, Nebr.a;
Date opened: October 1995.
Military treatment facilities as listed in implementation plan: 375th
Medical Group, Scott AFB, Ill.a;
Date opened: October 1995.
Military treatment facilities as listed in implementation plan: 72nd
Medical Group, Tinker AFB, Okla;
Date opened: February 2004.
Military treatment facilities as listed in implementation plan: 96th
Medical Group, Eglin AFB, Fla;
Date opened: October 2003.
Military treatment facilities as listed in implementation plan: 6th
Medical Group, MacDill AFB, Fla;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 74th
Medical Group, Wright Patterson AFB, Ohio;
Date opened: March 2004.
Military treatment facilities as listed in implementation plan: 16th
Medical Group, Hurlburt Field AFB, Fla;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 60th
Medical Group, Travis AFB, Calif.a;
Date opened: October 1995.
Military treatment facilities as listed in implementation plan: 99th
Medical Group, Nellis AFB, Nev;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 3rd Med
Group, Elmendorf AFB, Alaska;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 56th
Medical Group, Luke AFB, Ariz;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 42nd
Medical Group, Maxwell AFB, Ala;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 355
Medical Group, Davis Monthan AFB, Ariz;
Date opened: January 2004.
Military treatment facilities as listed in implementation plan: 89th
Medical Group, Andrews AFB, Md;
Date opened: October 2002.
Military treatment facilities as listed in implementation plan: 12th
Medical Group, Randolph AFB, Tex;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 78th
Medical Group, Robins AFB, Ga;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 305th
Medical Group, McGuire AFB, N.J;
Date opened: February 2004.
Military treatment facilities as listed in implementation plan: 377th
Medical Group, Kirtland AFB, N. Mex;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 43rd
Medical Group Pope AFB, N.C;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: 81st
Medical Group, Keesler AFB, Miss;
Date opened: October 2002.
Military treatment facilities as listed in implementation plan: 2nd
Medical Group, Barksdale AFB, La;
Date opened: February 2004.
Army:
Military treatment facilities as listed in implementation plan: Womack
Army Medical Center, Fort Bragg, N.C;
Date opened: January 2003.
Military treatment facilities as listed in implementation plan: Darnall
Army Community Hospital, Fort Hood, Tex;
Date opened: October 2002.
Military treatment facilities as listed in implementation plan: Martin
Army Community Hospital, Fort Benning, Ga.[A];
Date opened: October 1995.
Military treatment facilities as listed in implementation plan:
Blanchfield Army Community Hospital, Fort Campbell, Ky;
Date opened: December 2003.
Military treatment facilities as listed in implementation plan: Walter
Reed Army Medical Center, D.C.[A];
Date opened: September 1998.
Military treatment facilities as listed in implementation plan:
Kimbrough Ambulatory Care Center, Fort Meade, Md;
Date opened: October 2003.
Military treatment facilities as listed in implementation plan: Winn
Army Community Hospital, Fort Stewart, Ga;
Date opened: May 2003.
Military treatment facilities as listed in implementation plan: Madigan
Army Medical Center, Fort Lewis,Wash;
Date opened: April 2003.
Military treatment facilities as listed in implementation plan:
Reynolds Army Community Hospital, Fort Sill, Okla.[A];
Date opened: September 1995.
Military treatment facilities as listed in implementation plan: Ireland
Army Community Hospital, Fort Knox, Ky;
Date opened: July 2003.
Military treatment facilities as listed in implementation plan: Evans
Army Community Hospital, Fort Carson, Colo.[A];
Date opened: September 1995.
Military treatment facilities as listed in implementation plan: Tripler
Army Medical Center, Fort Shafter, Hawaii;
Date opened: May 2003.
Military treatment facilities as listed in implementation plan: General
Leonard Wood Army Community Hospital, Fort Leonard Wood, Mo;
Date opened: October 2003.
Military treatment facilities as listed in implementation plan:
Moncrief Army Community Hospital, Fort Jackson, S.C.[A];
Date opened: September 1995.
Military treatment facilities as listed in implementation plan:
Eisenhower Army Medical Center, Fort Gordon, Ga;
Date opened: July 2003.
Military treatment facilities as listed in implementation plan: William
Beaumont Army Medical Center, Fort Bliss, Tex;
Date opened: April 2003.
Military treatment facilities as listed in implementation plan: Dewitt
Army Community Hospital, Fort Belvoir, Va;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: Guthrie
Ambulatory Healthcare Clinic, Fort Drum, N.Y;
Date opened: January 2004.
Navy:
Military treatment facilities as listed in implementation plan: Naval
Medical Center, Portsmouth, Va;
Date opened: January 2003.
Military treatment facilities as listed in implementation plan: Naval
Medical Center, San Diego, Calif;
Date opened: September 2003.
Military treatment facilities as listed in implementation plan: Naval
Hospital, Camp Pendleton, Calif.[A];
Date opened: October 1995.
Military treatment facilities as listed in implementation plan: Naval
Hospital, Pensacola, Fla;
Date opened: September 2003.
Military treatment facilities as listed in implementation plan:
National Naval Medical Center, Bethesda, Md.[A];
Date opened: August 1999.
Military treatment facilities as listed in implementation plan: Naval
Hospital, Camp Lejeune, N.C.[A];
Date opened: September 1995.
Military treatment facilities as listed in implementation plan: Naval
Hospital, Jacksonville, Fla.[A];
Date opened: September 1995.
Military treatment facilities as listed in implementation plan: Naval
Hospital, Great Lakes, ll;
Date opened: October 2003.
Military treatment facilities as listed in implementation plan: Naval
Medical Clinic, Pearl Harbor, Hawaii;
Date opened: No clinic opened.
Military treatment facilities as listed in implementation plan: Naval
Hospital, Bremerton, Wash;
Date opened: September 2002.
Military treatment facilities as listed in implementation plan: Naval
Hospital, Cherry Point, N.C;
Date opened: January 2003.
Military treatment facilities as listed in implementation plan: Naval
Hospital, Beaufort, S.C;
Date opened: October 2002.
Sources: Report on Chiropractic Health Care Implementation Plan (August
2001), and the Offices of the Surgeons General for the Air Force, Army,
and Navy.
Note: Military treatment facilities are arranged by projected demand
based on population served by the Military Treatment Facility, within
service.
[A] Denotes clinics opened for the demonstration project, from fiscal
year 1995 through fiscal 2000.
[End of table]
Comments from the Department of Defense:
THE ASSISTANT SECRETARY OF DEFENSE:
HEALTH AFFAIRS:
WASHINGTON, D. C. 20301-1200:
AUG 12 2005:
Ms. Marcia Crosse:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Ms. Crosse:
This is the Department of Defense (DoD) response to the Government
Accountability Office (GAO) draft report, "DEFENSE HEALTH CARE: DoD Has
Established a Chiropractic Benefit for Active Duty Personnel," dated
July 21, 2005, (GAO Code 290253/GAO-05-890R).
Thank you for the opportunity to review the draft report. The report
makes no specific recommendations to the Department of Defense. We
concur with the draft report, but offer the enclosed comments and
suggestions to make it more technically accurate.
My points of contact are Ms. Anne Giese (Functional) at (703) 681-0039
and Mr. Gunther Zimmerman (Audit Liaison) at (703) 681-3492.
Sincerely,
Signed by:
William Winkenwerder, Jr., MD:
Enclosure: As stated:
GAO DRAFT REPORT - DATED July 21, 2005 GAO Code 290253/GAO-05-890R):
"DEFENSE HEALTH CARE: DoD Has Established a Chiropractic Benefit for
Active Duty Personnel"
DEPARTMENT OF DEFENSE COMMENTS:
OVERALL COMMENTS:
Oversight of the Chiropractic clinics is provided at the Service level.
The individual Services collect and analyze metrics for the programs at
their military treatment facilities. The Services have the
responsibility for monitoring execution of the Chiropractic program at
their facilities. The Services review the status of their sites on a
regular basis in order to renew contracts with the Chiropractors,
justify funding requests, and respond to legislative initiatives. TMA
is in frequent communication with the Services regarding medical care,
budget and legislative issues that impact the Chiropractic care program
across the military health system. Data collected by the Services are
most useful during the discussions with TMA on issues that affect the
entire military health system.
(290253):
FOOTNOTES
[1] Pub. L. No. 106-398, App. A, § 702, 114 Stat. 1654, 1654A-173-174
(2000).
[2] An MTF is a military hospital or clinic on or near a military base.
[3] Pub. L. No. 103-337, § 731, 108 Stat. 2663, 2809 (1994) (NDAA
1995).
[4] We did not evaluate the development of DOD's implementation plan
because of our previous role as a member of the OAC in accordance with
NDAA 1995. In our role, we participated in developing DOD's
implementation plan by providing the OAC with a member. To maintain
compliance with the independence requirements of generally accepted
government auditing standards, we are unable to evaluate the
development of that same plan.
[5] In addition to members of the armed forces, "active-duty personnel"
also include members of the Coast Guard, the Commissioned Corps of the
National Oceanic and Atmospheric Administration, and the Public Health
Service. Members of the Reserves and National Guard are also eligible
for care in the military health system when they are in active-duty
status for over 30 days.
[6] Pub. L. No. 98-525, § 632(b), 98 Stat. 2492, 2543 (1984).
[7] Pub. L. No. 103-337, § 731, 108 Stat. 2663, 2809 (1994).
[8] Pub. L. No. 105-85, § 739(a), (b), 111 Stat. 1629, 1815 (1997).
[9] We did not adjust the $70 million figure to 2005 dollars. The
figure is taken from DOD's February 2000 report and is in 2000 dollars.
[10] Congress did not direct that DOD's plan include the provision of
the benefit to military retirees and dependents.
[11] S. Rep. No. 108-46 at 331-332 (2003).
[12] On May 13, 2005, DOD made recommendations for base realignments
and closures. Thirty-six bases that have MTFs with chiropractic clinics
would be affected if these recommendations are implemented; 16 would be
realigned and 20 would gain additional staff or functions. DOD defines
"realignment" as any action that both reduces and relocates functions
and civilian personnel positions. DOD has not determined how this would
affect the chiropractic program.
