Questions for the Record Related to the Benefits and Medical Care for Federal Civilian Employees Deployed to Afghanistan and Iraq
Gao ID: GAO-08-155R October 16, 2007GAO appeared before the House Subcommittee on Oversight and Investigations, Committee on Armed Services on September 18, 2007, to discuss the benefits and medical care for federal civilian and U.S. government contract employees deployed to Iraq and Afghanistan. This report responds to Congress' request that GAO provide answers to questions for the record from the hearing. The questions are (1) What are the congressional requirements for medical tracking of deployed military servicemembers and civilians? and (2) What work has GAO conducted on this topic?
Following GAO's May 1997 report, Congress enacted legislation3 that required the Secretary of Defense to establish a medical tracking system to assess the medical condition of servicemembers before and after deployments to locations outside of the United States. This legislation was amended by a provision in the John Warner National Defense Authorization Act for Fiscal Year 2007. The current legislation amends elements of the system and the quality assurance program as well as adds criteria for referral for further evaluations and minimum mental health standards for deployment. Since the 1990s, GAO has highlighted shortcomings with respect to the Department of Defense's (DOD) ability to assess the medical condition of servicemembers both before and after their deployments. Following GAO's May 1997 report, Congress enacted legislation that required the Secretary of Defense to establish a medical tracking system for assessing the medical condition of servicemembers before and after deployments. In September 2003, we reported that the Army and Air Force did not comply with DOD's force health protection and surveillance requirements for many servicemembers deploying in support of Operation Enduring Freedom in Central Asia and Operation Joint Guardian in Kosovo. Our report also raised concerns over a lack of DOD oversight of departmentwide efforts to comply with health surveillance requirements. In September 2004, we reported similar issues related to DOD's ability to effectively manage the health status of its reserve forces. In November 2004, we reported that overall compliance with DOD's force health protection and surveillance policies for servicemembers who deployed in support of Operation Iraqi Freedom varied by service, by installation, and by policy requirement. In October 2005, we reported that evidence suggested that reserve component members have deployed into theater with preexisting medical conditions that could not be adequately addressed in theater, and that DOD had 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. In February 2007, the Office of the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness published a new instruction on force health protection quality assurance. This policy applies to military servicemembers, as well as applicable DOD and contractor personnel. The new policy requires the military services to implement procedures to monitor key force health protection elements such as pre- and post-deployment health assessments. In our June 2007 report on DOD's compliance with the legislative requirement to perform pre- and post-deployment medical examinations on servicemembers, DOD lacked a comprehensive oversight framework to help ensure effective implementation of its deployment health quality assurance program, which included specific reporting requirements and results-oriented performance measures to evaluate the services' adherence to deployment health requirements.
GAO-08-155R, Questions for the Record Related to the Benefits and Medical Care for Federal Civilian Employees Deployed to Afghanistan and Iraq
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October 16, 2007:
The Honorable Vic Snyder:
Chairman:
Subcommittee on Oversight and Investigations:
Committee on Armed Services:
House of Representatives:
Subject: Questions for the Record Related to the Benefits and Medical
Care for Federal Civilian Employees Deployed to Afghanistan and Iraq:
It was a pleasure to appear before your Subcommittee on September 18,
2007, to discuss the benefits and medical care for federal civilian and
U.S. government contract employees deployed to Iraq and
Afghanistan.[Footnote 1] This letter responds to your request that I
provide answers to questions for the record from the hearing. The
questions, along with my responses, follow.
1. What are the congressional requirements for medical tracking of
deployed military servicemembers and civilians?
Following GAO's May 1997 report,[Footnote 2] Congress enacted
legislation[Footnote 3] that required the Secretary of Defense to
establish a medical tracking system to assess the medical condition of
servicemembers before and after deployments to locations outside of the
United States.Specifically, the legislation required the following:
"(a) System Required--The Secretary of Defense shall establish a system
to assess the medical condition of members of the armed forces
(including members of the reserve components) who are deployed outside
the United States or its territories or possessions as part of a
contingency operation (including a humanitarian operation, peacekeeping
operation, or similar operation) or combat operation.
"(b) Elements Of System--The system described in subsection (a) shall
include the use of predeployment medical examinations and
postdeployment medical examinations (including an assessment of mental
health and the drawing of blood samples) to accurately record the
medical condition of members before their deployment and any changes in
their medical condition during the course of their deployment. The
postdeployment examination shall be conducted when the member is
redeployed or otherwise leaves an area in which the system is in
operation (or as soon as possible thereafter).
"(c) Recordkeeping--The results of all medical examinations conducted
under the system, records of all health care services (including
immunizations) received by members described in subsection (a) in
anticipation of their deployment or during the course of their
deployment, and records of events occurring in the deployment area that
may affect the health of such members shall be retained and maintained
in a centralized location to improve future access to the records.
"(d) Quality Assurance--The Secretary of Defense shall establish a
quality assurance program to evaluate the success of the system in
ensuring that members described in subsection (a) receive predeployment
medical examinations and postdeployment medical examinations and that
the recordkeeping requirements with respect to the system are met."
This legislation was amended by a provision in the John Warner National
Defense Authorization Act for Fiscal Year 2007.[Footnote 4] The current
legislation amends elements of the system and the quality assurance
program as well as adds criteria for referral for further evaluations
and minimum mental health standards for deployment. Specifically, the
current legislation requires the following:
"(a) System Required--Not changed by the current legislation.
"(b) Elements Of System--:
(1) The system described in subsection (a) shall include the use of
predeployment medical examinations and postdeployment medical
examinations (including an assessment of mental health and the drawing
of blood samples) to accurately record the medical condition of members
before their deployment and any changes in their medical condition
during the course of their deployment. The postdeployment examination
shall be conducted when the member is redeployed or otherwise leaves an
area in which the system is in operation (or as soon as possible
thereafter).
(2) The predeployment and postdeployment medical examination of a
member of the armed forces required under paragraph (1) shall include
the following:
(A) An assessment of the current treatment of the member and any use of
psychotropic medications by the member for a mental health condition or
disorder.
(B) An assessment of traumatic brain injury.
"(c) RECORDKEEPING--Not changed by the current legislation.
"(d) QUALITY ASSURANCE--:
(1) The Secretary of Defense shall establish a quality assurance
program to evaluate the success of the system in ensuring that members
described in subsection (a) receive predeployment medical examinations
and postdeployment medical examinations and that the recordkeeping
requirements with respect to the system are met.
(2) The quality assurance program established under paragraph (1) shall
also include the following elements:
(A) The types of healthcare providers conducting postdeployment health
assessments.
(B) The training received by such providers applicable to the conduct
of such assessments, including training on assessments and referrals
relating to mental health.
(C) The guidance available to such providers on how to apply the
clinical practice guidelines developed under subsection (e)(1) in
determining whether to make a referral for further evaluation of a
member of the armed forces relating to mental health.
(D) The effectiveness of the tracking mechanisms required under this
section in ensuring that members who receive referrals for further
evaluations relating to mental health receive such evaluations and
obtain such care and services as are warranted.
(E) Programs established for monitoring the mental health of each
member who, after deployment to a combat operation or contingency
operations, is known--:
(i) to have a mental health condition or disorder; or:
(ii) to be receiving treatment, including psychotropic medications, for
a mental health condition or disorder.
"(e) Criteria For Referral For Further Evaluations--The system
described in subsection (a) shall include--:
(1) development of clinical practice guidelines to be utilized by
healthcare providers in determining whether to refer a member of the
armed forces for further evaluation relating to mental health
(including traumatic brain injury);
(2) mechanisms to ensure that healthcare providers are trained in the
application of such clinical practice guidelines; and:
(3) mechanisms for oversight to ensure that healthcare providers apply
such guidelines consistently.
"(f) Minimum mental health standards for deployment--:
(1) The Secretary of Defense shall prescribe in regulations minimum
standards for mental health for the eligibility of a member of the
armed forces for deployment to a combat operation or contingency
operation.
(2) The standards required by paragraph (1) shall include the
following:
(A) A specification of the mental health conditions, treatment for such
conditions, and receipt of psychotropic medications for such conditions
that preclude deployment of a member of the armed forces to a combat
operation or contingency operation, or to a specified type of such
operation.
(B) Guidelines for the deployability and treatment of members of the
armed forces diagnosed with a severe mental illness or post traumatic
stress disorder.
(3) The Secretary shall take appropriate actions to ensure the
utilization of the standards prescribed under paragraph (1) in the
making of determinations regarding the deployability of members of the
armed forces to a combat operation or contingency operation."
2. What work has GAO conducted on this topic?
Since the 1990s, GAO has highlighted shortcomings with respect to the
Department of Defense's (DOD) ability to assess the medical condition
of servicemembers both before and after their deployments. Following
GAO's May 1997 report, Congress enacted legislation (codified at 10
U.S.C. § 1074f) that required the Secretary of Defense to establish a
medical tracking system for assessing the medical condition of
servicemembers before and after deployments.
In September 2003, we reported that the Army and Air Force did not
comply with DOD's force health protection and surveillance requirements
for many servicemembers deploying in support of Operation Enduring
Freedom in Central Asia and Operation Joint Guardian in
Kosovo.[Footnote 5] Specifically, our review disclosed problems with
the Army's and Air Force's implementation of DOD's force health
protection and surveillance requirements in the following areas: (1)
deployment health assessments, (2) immunizations and other
predeployment requirements, and (3) the completeness of medical records
and centralized data collection. Our September 2003 report also raised
concerns over a lack of DOD oversight of departmentwide efforts to
comply with health surveillance requirements. Specifically, we reported
that an effective quality assurance program had not been established at
the Office of the Assistant Secretary of Defense for Health Affairs or
at the Offices of the Surgeons' General of the Army or Air Force to
help ensure compliance with force health protection and surveillance
policies. We believed that the lack of such a system was a major cause
of the high rate of noncompliance and thus recommended that the
department establish an effective quality assurance program to ensure
that the military services comply with the force health protection and
surveillance requirements for all servicemembers. The department
concurred with our recommendation, and in January 2004 began
implementation of its deployment health quality assurance program.
In September 2004, we reported similar issues related to DOD's ability
to effectively manage the health status of its reserve forces.[Footnote
6] Specifically we noted that DOD's centralized database had missing
and incomplete predeployment health assessment questionnaires because
not all of the required health information collected from reserve
component members had reached DOD's central data collection point. We
recommended that the Secretary of Defense take steps to ensure that
predeployment health assessment questionnaires are submitted to the
centralized data collection point as required. DOD concurred with our
recommendation and noted that revised guidance was currently in
coordination to clarify the requirement for submitting predeployment
health assessments to the centralized database.
In November 2004, we reported that overall compliance with DOD's force
health protection and surveillance policies for servicemembers who
deployed in support of Operation Iraqi Freedom varied by service, by
installation, and by policy requirement.[Footnote 7] At that time, we
did not evaluate the effectiveness of DOD's deployment health quality
assurance program because of the relatively short time of its
implementation.
In October 2005, we reported that evidence suggested that reserve
component members have deployed into theater with preexisting medical
conditions that could not be adequately addressed in theater.[Footnote
8] We also reported that DOD had 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. We recommended that the
Secretary of Defense determine what preexisting medical conditions
should not be allowed into specific theaters of operations 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. We also recommended that the Secretary of Defense
explore using existing tracking systems to track those who have
treatable preexisting medical conditions in theater. DOD partially
concurred with our recommendation concerning the identification of
preexisting medical conditions that would preclude deployment and noted
that the services had made advances in identifying some preexisting
conditions that would preclude deployment, but also stated that due to
the ever changing nature of theater of operations this list could never
be fully comprehensive or fully enforceable. DOD also concurred with
our recommendation pertaining to the use of existing tracking systems
to track treatable preexisting medical conditions. Specifically, DOD
indicated that ongoing refinements to these systems based on lessons
learned would improve the documentation of medical conditions
throughout the military services including information concerning
reserve members with preexisting conditions.
As we noted in our statement, our September 2006 report[Footnote 9] on
DOD's policies concerning its federal civilians who have deployed in
support of operations in Afghanistan and Iraq found that DOD has
established force health protection and surveillance policies aimed at
assessing and reducing or preventing health risks for its deployed
federal civilian personnel; however, at the time of our review, the
department lacked a quality assurance mechanism to ensure the
components' full implementation of its policies. To strengthen DOD's
force health protection and surveillance for its deployed federal
civilians, we recommended that DOD establish an oversight and quality
assurance mechanism to ensure that all components fully comply with its
requirements. In February 2007, the Office of the Deputy Assistant
Secretary of Defense for Force Health Protection and Readiness
published a new instruction[Footnote 10] on force health protection
quality assurance. This policy applies to military servicemembers, as
well as applicable DOD and contractor personnel. The new policy
requires the military services to implement procedures to monitor key
force health protection elements such as pre-and post-deployment health
assessments. In addition, the policy requires each military service to
report its force health protection and quality assurance findings to
the Assistant Secretary of Defense (Health Affairs) through the Deputy
Assistant Secretary of Defense for Force Health Protection and
Readiness.
We further noted in our statement that, in our June 2007
report[Footnote 11] on DOD's compliance with the legislative
requirement to perform pre-and post-deployment medical examinations on
servicemembers, DOD lacked a comprehensive oversight framework to help
ensure effective implementation of its deployment health quality
assurance program, which included specific reporting requirements and
results-oriented performance measures to evaluate the services'
adherence to deployment health requirements. Also, we noted in our
statement that the department's new instruction and planned actions
indicate that DOD is taking steps in the right direction. We stated and
still believe that if the department follows through with its efforts,
it will be responsive to several of our reports' recommendations to
improve DOD's force health protection and surveillance for the Total
Force.
For additional information on our work on military and civilian
personnel, and DOD health care issues, please contact me on (202) 512-
3604 or farrellb@gao.gov.
Signed by:
Brenda S. Farrell:
Director, Defense Capabilities and:
Management:
[End of section]
Footnotes:
[1] GAO, DOD Civilian Personnel: Medical Policies for Deployed DOD
Federal Civilians and Associated Compensation for Those Deployed, GAO-
07-1235T (Washington, D.C.: Sept. 18, 2007).
[2] GAO, Defense Health Care: Medical Surveillance Improved Since Gulf
War, but Mixed Results in Bosnia, GAO/NSIAD-97-136 (Washington, D.C.:
May 13, 1997).
[3] National Defense Authorization Act for Fiscal Year 1998, Pub. L.
No. 105-85, § 765 (1997) (codified at 10 U.S.C. § 1074f). DOD
established force health protection and surveillance policies aimed at
assessing and reducing or preventing health risks for its deployed
federal civilian personnel.
[4] John Warner National Defense Authorization Act for Fiscal Year
2007, Pub. L. No. 109-364, § 738 (2006) (codified at 10 U.S.C. §
1074f).
[5] GAO, Defense Health Care: Quality Assurance Process Needed to
Improve Force Health Protection and Surveillance, GAO-03-1041
(Washington, D.C.: Sept. 19, 2003).
[6] 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).
[7] GAO, Defense Health Care: Force Health Protection and Surveillance
Policy Compliance Was Mixed, but Appears Better for Recent Deployments,
GAO-05-120 (Washington, D.C.: Nov. 12, 2004).
[8] GAO, 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. (Washington. D.C.: Oct. 27,
2005).
[9] GAO, DOD Civilian Personnel: Greater Oversight and Quality
Assurance Needed to Ensure Force Health Protection and Surveillance for
Those Deployed, GAO-06-1085 (Washington, D.C.: Sept. 29, 2006).
[10] DOD Instruction 6200.05, Force Health Protection (FHP) Quality
Assurance Program, February 16, 2007.
[11] GAO, Defense Health Care: Comprehensive Oversight Framework Needed
to Help Ensure Effective Implementation of a Deployment Health Quality
Assurance Program, GAO-07-831 (Washington, D.C.: June 22, 2007).
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