Defense Health Care: Army Needs to Assess the Health Status of
All Early-Deploying Reservists (15-APR-03, GAO-03-437).
During the 1990-1991 Persian Gulf War, health problems prevented
the deployment of a significant number of Army reservists. To
help correct this problem the Congress passed legislation that
required reservists to undergo periodic physical and dental
examinations. The National Defense Authorization Act for 2002
directed GAO to review the value and advisability of providing
examinations. GAO also examined whether the Army is collecting
and maintaining information on reservist health. GAO obtained
expert opinion on the value of periodic examinations and visited
seven Army reserve units to obtain information on the number of
examinations that have been conducted.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-03-437
ACCNO: A06663
TITLE: Defense Health Care: Army Needs to Assess the Health
Status of All Early-Deploying Reservists
DATE: 04/15/2003
SUBJECT: Armed forces reserves
Army reservists
Combat readiness
Health care services
Medical information systems
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GAO-03-437
Report to Congressional Committees
United States General Accounting Office
GAO
April 2003 DEFENSE HEALTH CARE
Army Needs to Assess the Health Status of All Early- Deploying Reservists
GAO- 03- 437
Medical experts recommend periodic physical and dental examinations as an
effective means of assessing health. Periodic physical and dental
examinations for early- deploying reservists provide a means for the Army
to
determine their health status. Army early- deploying reservists need to be
healthy to meet the specific demands of their occupations; examinations
and other health screenings can be used to identify those who cannot
perform their assigned duties. Without adequate examinations, the Army may
train, support, and mobilize reservists who are unfit for duty.
The Army has not consistently carried out the statutory requirements for
monitoring the health and dental status of Army early- deploying
reservists. At the early- deploying units GAO visited, approximately 66
percent of the medical records were available for review. For example, we
found that about 68 percent of the required 2- year physical examinations
for those over age 40 had not been performed and that none of the annual
medical certificates required of reservists were completed by reservists
and reviewed by the units.
The Army*s automated health care information system does not contain
comprehensive physical and dental information on early- deploying
reservists. According to Army officials, in 2003 the Army plans to expand
its system to maintain accurate and complete medical and dental
information to monitor the health status of early- deploying reservists.
Site Visit Results for Seven U. S. Army Reserve Units
13 68
100 49
0 20
40 60
80 100
Reservists without a 5- year physical Reservists
without a 2- year physical
Reservists without a self certification
Reservists without a dental
examination Percentage
Source: GAO analysis of Army data. During the 1990- 1991 Persian Gulf War,
health problems prevented the deployment of a significant
number of Army reservists. To help correct this problem the Congress
passed legislation that required reservists to undergo periodic physical
and dental examinations. The National Defense Authorization Act for 2002
directed GAO to review the value and advisability of providing
examinations. GAO also examined
whether the Army is collecting and maintaining information on reservist
health. GAO obtained expert opinion on the value of periodic examinations
and visited seven Army reserve units to obtain
information on the number of examinations that have been conducted. GAO
recommends that the
Secretary of Defense ensure that for early- deploying reservists 5- year
physical examinations
for those under 40 and 2- year physical examinations for those over 40 are
complete; annual medical certificates are
complete and that they are reviewed by the Army; and annual dental
examinations and needed treatments are complete.
DOD concurred with the recommendations.
www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 437. To view the full report,
including the scope and methodology, click on the link above. For more
information, contact Marjorie E. Kanof at (202) 512- 7101. Highlights of
GAO- 03- 437, a report to
Congressional Committees
April 2003
DEFENSE HEALTH CARE
Army Needs to Assess the Health Status of All Early- Deploying Reservists
Page i GAO- 03- 437 Assessing Health Status of Army Reservists Letter 1
Results in Brief 3 Background 4 Periodic Physical and Dental Examinations
Are Valuable for
Assessing Health Status and Provide Beneficial Information to the Army 8
The Army Has Not Collected and Maintained All Required Medical
and Dental Information on Early- Deploying Reservists 12 Conclusions 13
Recommendations for Executive Action 14 Agency Comments and Our Evaluation
15 Appendix I Scope and Methodology 18
Appendix II Army Physical Profile Rating Guide 19
Appendix III Annual Medical Certificate 21
Appendix IV Comments from the Department of Defense 23
Appendix V GAO Contact and Staff Acknowledgments 27 GAO Contact 27
Acknowledgments 27 Related GAO Products 28
Table
Table 1: DOD Dental Classifications and Their Description 7 Contents
Page ii GAO- 03- 437 Assessing Health Status of Army Reservists
Abbreviations
DOD Department of Defense DNA deoxyribonucleic acid FEDS_ HEAL Federal
Strategic Health Care Alliance HHS Department of Health and Human Services
HIV human immunodeficiency virus MMRB Military Occupational Specialty/
Medical Retention
Board
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Page 1 GAO- 03- 437 Assessing Health Status of Army Reservists
April 15, 2003 Congressional Committees The Department of the Army (Army)
is increasingly relying on its 560,000 reservists to supplement the
capabilities of our nation*s active duty forces for peacetime support
operations as well as for war. 1 Of these reservists, approximately 90,000
are specifically designated as early- deploying reservists. 2 Because of
this designation, they are entitled to health benefits not afforded to
other reservists. The remaining reservists* about
470,000* become early- deploying reservists 75 days prior to their
scheduled deployment date, at which time they are entitled to the same
benefits afforded to those who are specifically designated as
earlydeploying reservists.
When reservists were mobilized during the Persian Gulf War in 1990- 1991,
the Army discovered that due to medical reasons or poor dental status a
significant number of them could not be deployed or had their deployment
delayed. 3 In an effort to obviate similar problems, the Congress passed
four statutory requirements to monitor the health status of those
designated as early- deploying reservists. These requirements are in
addition to two requirements that had been in place prior to the Persian
Gulf War. To meet these requirements, the Army is to provide annual
medical screenings, annual dental screenings, selected dental treatment,
and for those over age 40, physical examinations every 2 years.
Earlydeploying reservists are required to disclose annually to the Army
the status of their physical and dental condition, and those under age 40
are required to undergo a physical examination once every 5 years. These
six
1 The Army reserve components consist of the U. S. Army Reserve and the
Army National Guard. The Army National Guard component carries out a dual
mission. It is responsive both to the federal government for national
security missions and to governors for state missions. 2 To support its
mission needs and war plans the Army has established Force Support
Packages 1 and 2* a group of reservists who would normally be the first to
be deployed in a ground conflict. In this report we refer to these
reservists as early- deploying reservists.
3 Mobilization is the process by which the armed forces are brought into a
state of readiness for war or national emergency or to support some other
operational mission. In this report, mobilization means calling up reserve
components for active duty. Deployment involves the relocation of
mobilized forces and materiel to desired areas of operation. United States
General Accounting Office Washington, DC 20548
Page 2 GAO- 03- 437 Assessing Health Status of Army Reservists
requirements are used to help ensure that the reservists meet the
military*s health standards so they are ready to perform their assigned
duties.
The National Defense Authorization Act for Fiscal Year 2002 directed that
we obtain information on the value of periodic physical and dental
examinations and determine the advisability of the statutory requirements
for the Army*s early- deploying reservists. We also agreed with the
committees of jurisdiction to determine if the Army is collecting and
maintaining information on the health status of its early- deploying
reservists.
To answer these questions we focused our work on units that have been
specifically designated as early- deploying reservists. We visited seven
early- deploying U. S. Army Reserve units in the states of Georgia,
Maryland, and Texas and reviewed all available medical and dental records
of reservists assigned to those units. However, our analysis of the
information gathered at these units is not projectable. We reviewed U. S.
Army Reserve medical policies and regulations pertaining to earlydeploying
reservists. We also reviewed Army National Guard policies and procedures
governing reservists* health care but did not review medical or dental
records at Army National Guard units. Additionally, we analyzed Army data
showing the cost to perform periodic physical and dental
examinations 4 and to provide dental treatment. We reviewed studies from
the Department of Defense (DOD) including its 1999 report to the Congress
on ways to improve the medical and dental care provided to reservists. 5
We also reviewed studies and information on the effectiveness of periodic
physical and dental examinations published by the Department of Health and
Human Services (HHS), the National Institutes of Health, the American
Medical Association, the Academy of General Dentistry, and others. We
interviewed DOD officials in the offices of the Assistant Secretary of
Defense for Reserve Affairs and the Assistant Secretary for Health
Affairs, and officials in the Office of the Surgeon General, U. S. Army
Forces Command and the Office of the Surgeon General, U. S. Army
4 10 U. S. C. S:1074a( d)( 1)( C) requires the Army to provide early-
deploying reservists with a dental screening. While a dental screening
does not have to be performed by a dentist, the Army requires its early-
deploying reservists to be examined by a dentist to fulfill the
screening requirement. Therefore, in this report we use the term
*examination* rather than *screening.* 5 Report To Congress: Means of
Improving the Provision of Uniform and Consistent Medical and Dental Care
to Members of the Reserve Components (Washington, D. C.: October 1999).
Page 3 GAO- 03- 437 Assessing Health Status of Army Reservists
Reserve Command to obtain information on the health care provided to Army
early- deploying reservists. (For more on our scope and methodology, see
app. I.) We conducted our work from May 2002 through April 2003 in
accordance with generally accepted government auditing standards.
Periodic physical and dental examinations for early- deploying reservists
are valuable for the Army because such examinations provide a means of
determining reservists* health status and ensuring the medical readiness
of reserve forces. Medical experts recommend periodic physical and dental
examinations as an effective means of assessing health. Because Army
early- deploying reservists need to be healthy to meet the specific
demands of their occupations, examinations and other health screenings can
be used to identify those who cannot perform their assigned duties.
Without adequate examinations, the Army runs the risk of mobilizing
earlydeploying reservists who cannot be deployed because of their health.
In the case of early- deploying reservists who cannot be deployed, the
Army
loses not only the amount it invested in salaries and training but also
the particular skill or occupation it was relying on to fill a specific
military need.
The Army has not consistently carried out the statutory requirements for
monitoring the health and dental status of Army early- deploying
reservists. At the seven U. S. Army Reserve early- deploying units we
visited, approximately 66 percent of the medical records were available
for our review. Army administrators told us that the remaining files were
in transit, with the reservist, or on file at another location. Based on
our review of available records, we found that about 13 percent of the 5-
year physical examinations had not been performed, and none of the annual
medical certificates had been completed by reservists and reviewed by the
units. Furthermore, 49 percent of early- deploying reservists lacked a
current dental examination and 68 percent of those over the age of 40
lacked a current biennial physical examination. In addition, the Army does
not have an automated system for maintaining accurate and complete medical
information on early- deploying reservists.
We are recommending that the Secretary of Defense direct the Secretary of
the Army to fully comply with the six statutory requirements. In
commenting on a draft of this report, DOD concurred with the report*s
recommendations. Results in Brief
Page 4 GAO- 03- 437 Assessing Health Status of Army Reservists
In recent years, reservists have regularly been called on to augment the
capabilities of the active- duty forces. The Army is increasingly relying
on its reserve forces to provide assistance with military conflicts and
peacekeeping missions. As of April 2003, approximately 148, 000 reservists
6 from the Army National Guard and the U. S. Army Reserve were mobilized
to active duty positions. In addition, other reservists are serving
throughout the world in peacekeeping missions in the Balkans, Africa,
Latin America, and the Pacific Rim. The involvement of reservists in
military operations of all sizes, from small humanitarian missions to
major theater wars, will likely continue under the military*s current war
fighting strategy and its peacetime support operations.
The Army has designated some Army National Guard and U. S. Army Reserve
units and individuals as early- deploying reservists to ensure that forces
are available to respond rapidly to an unexpected event or for any other
need. Usually, those designated as early- deploying reservists would be
the first troops mobilized if two major ground wars were underway
concurrently. The units and individual reservists designated as
earlydeploying reservists change as the missions or war plans change. The
Army estimates that of its 560,000 reservists, approximately 90, 000 are
reservists who have been individually categorized as early- deploying
reservists or are reservists who are assigned to Army National Guard and
U. S. Army Reserve units that have been designated as early- deploying
units.
The Army must comply with the following six statutory requirements that
are designed to help ensure the medical and dental readiness of its
earlydeploying reservists.
All reservists including early- deployers are required to have a 5-
year physical examination, 7 and complete an annual certificate of
physical condition. 8 6 The number of reservists mobilized changes on a
continuous basis as certain reservists are
released and others are called- up, as mission needs change. 7 10 U. S. C.
S:10206( a)( 1)( 2000). 8 10 U. S. C. S:10206( a)( 2)( 2000). Background
Page 5 GAO- 03- 437 Assessing Health Status of Army Reservists
All early- deploying reservists are also required to have a biennial
physical examination if over age 40, 9 an annual medical screening, 10
an annual dental screening, 11 and
dental treatment. 12 Army regulations state that the 5- and 2- year
physical examinations are designed to provide the information needed to
identify health risks, suggest lifestyle modifications, and initiate
treatment of illnesses. While the two examinations are similar, the
biennial examination for earlydeploying reservists over age 40 13 contains
additional age- specific screenings such as a prostate examination, a
prostate- specific antigen test, and a fasting lipid profile that includes
testing for total cholesterol, lowdensity lipoproteins, and high- density
lipoproteins. The Army pays for these examinations.
The examinations are also used to assign early- deploying reservists a
physical profile rating, ranging from P1 to P4, in six assessment areas:
(a) Physical capacity, (b) Upper extremities, (c) Lower extremities, (d)
Hearing- ears, (e) Vision- eyes, and (f) Psychiatric. (See app. II for the
Army*s Physical Profile Rating Guide.) According to the Army, P1
represents a non- duty- limiting condition, meaning that the individual is
fit for duty and possesses no physical or psychiatric impairments. P2
means a condition may exist; however, it is not duty- limiting. P3 or P4
means that the individual has a duty- limiting condition in one of the six
assessment areas. P4 means the individual functions below the P3 level. A
rating of either P3 or P4 puts the reservist in a nondeployable status or
may result in the changing of the reservist*s job classification.
9 10 U. S. C. S:1074a( d)( 1)( B)( 2000). 10 10 U. S. C. S:1074a( d)( 1)(
A)( 2000). 11 10 U. S. C. S:1074a( d)( 1)( C)( 2000). 12 10 U. S. C.
S:1074a( d)( 1)( D)( 2000). 13 Approximately 22,500 early- deploying
reservists are over age 40.
Page 6 GAO- 03- 437 Assessing Health Status of Army Reservists
Beginning in January 2003, early- deploying reservists with a permanent
rating of P3 or P4 14 in one of the assessment areas must be evaluated by
an administrative screening board* the Military Occupational Specialty/
Medical Retention Board (MMRB). This evaluation determines if reservists
can satisfactorily perform the physical requirements of their jobs. The
MMRB recommends whether a reservist should retain a job, be reassigned, or
be discharged from the military.
Army regulations that implement the statutory certification requirement
provide that all reservists* including early- deploying reservists*
certify their physical condition annually on a two- page certification
form. Army early- deploying reservists must report doctor or dentist
visits since their last examination, describe current medical or dental
problems, and disclose any medications they are currently taking. (See
app. III for a copy of the annual medical certificate* DA Form 7349.) In
addition, the Army is required to conduct an annual medical screening for
all early- deploying reservists. According to Army regulations, the Army
is to meet the annual medical screening requirement by reviewing the
medical certificate required of each early- deploying reservist.
In addition, Army early- deploying reservists are required to undergo, at
the Army*s expense, an annual dental examination. The Army is also
required to provide and pay for the dental treatment needed to bring an
earlydeploying reservist*s dental status up to deployment standards*
either dental class 1 or 2. (See table 1 for a general description of each
dental classification.)
14 A permanent rating of P3 or P4 exists when the condition that caused it
is not likely to improve.
Page 7 GAO- 03- 437 Assessing Health Status of Army Reservists
Table 1: DOD Dental Classifications and Their Description Class 1
reservist is deployable
Class 2 reservist is deployable
Class 3 reservist is nondeployable Class 4
reservist is nondeployable Reservists not
requiring dental treatment or reevaluation within 12 months.
Reservists who have oral conditions that, if not treated or followed up,
have
the potential but are not expected to result in dental emergencies within
12 months.
Reservists who have oral conditions that if not treated are expected to
result in dental emergencies within 12 months. Reservists should be placed
in Class 3
when there are questions in determining classification between Class 2 and
Class 3.
Reservists who have not had the required annual dental examination.
Source: DOD. Note: DOD Policy Memorandum, Policies on Uniformity of Dental
Classification System, Frequency of Periodic Dental Examinations, Active
Duty Overseas Screening, and Dental Deployment Standards (Washington, D.
C.: Feb. 19, 1998).
According to Army officials, most of the 5- year and 2- year physical
examinations, the dental examinations, and the dental treatments that have
been performed were administered by military medical personnel. However,
beginning in March 2001, the Army started outsourcing some examinations
through the Federal Strategic Healthcare Alliance
(FEDS_ HEAL)* an alliance of private physicians and dentists and other
physicians and dentists who work for the Department of Veterans Affairs
and HHS*s Division of Federal Occupational Health. FEDS_ HEAL is a program
that allows Army early- deploying reservists to obtain required physical
and dental examinations and dental treatment from local providers. The
Army contracts and pays for these examinations. About 12,000 of these
providers nationwide participate in FEDS_ HEAL. The Army plans to increase
its reliance on FEDS_ HEAL to provide physical and dental examinations,
and dental treatment for early- deploying reservists.
Page 8 GAO- 03- 437 Assessing Health Status of Army Reservists
Medical experts recommend physical and dental examinations as an effective
means of assessing health. For some people, the frequency and content of
physical examinations vary according to the specific demands of their job.
Because Army early- deploying reservists need to be healthy to fulfill
their professional responsibilities, periodic examinations are useful for
assessing whether they can perform their assigned duties. Furthermore, the
estimated annual cost to conduct periodic examinations* about $140* is
relatively modest compared to the thousands of dollars the Army spends for
salaries and training of earlydeploying reservists* an investment that may
be lost if reservists can not perform their assigned duties.
Physical and dental examinations are geared towards assessing and
improving the overall health of the general population. The U. S.
Preventive Services Task Force 15 and many other medical organizations no
longer recommend annual physical examinations for adults* preferring
instead a more selective approach to detecting and preventing health
problems. In 1996, the task force reported that while visits with primary
care clinicians are important, performing the same interventions annually
on all patients is not the most clinically effective approach to disease
prevention. 16 Consistent with its finding, the task force recommended
that the frequency
and content of periodic health examinations should be based on the unique
health risks of individual patients. Today, many health associations and
organizations are recommending periodic health examinations that
incorporate age- specific screenings, such as cholesterol screenings for
men (beginning at age 35) and women (beginning at age 45) every 5 years,
and clinical breast examinations every 3 to 5 years for women between the
ages of 19 and 39. Further, oral health care experts emphasize the
importance of regular 6- to 12- month dental examinations.
Both the private and public sectors have established a fixed schedule of
physical examinations for certain occupations to help ensure that workers
are healthy enough to meet the specific demands of their jobs. For
15 The U. S. Preventive Services Task Force was established by the U. S.
Public Health Service in 1984 as an independent panel of experts to review
the effectiveness of clinical preventive services* screening tests for
early detection of disease, immunizations to prevent infections, and
counseling for risk reduction.
16 Guide to Clinical Preventive Services, Second Edition* 1996, Report of
the U. S. Preventive Services Task Force, HHS Office of Public Health and
Science, Office of Disease Prevention and Health Promotion. Periodic
Physical and
Dental Examinations Are Valuable for Assessing Health Status and Provide
Beneficial Information to the Army
Experts Look to Screenings and Examinations as Key Indicators of Health
Page 9 GAO- 03- 437 Assessing Health Status of Army Reservists
example, the Federal Aviation Administration requires commercial pilots to
undergo a physical examination once every 6 months. U. S. National Park
Service personnel who perform physically demanding duties have a physical
examination once every other year for those under age 40, and on an annual
basis for those over age 40. Additionally, guidelines published by the
National Fire Protection Association recommend that firefighters have
an annual physical examination regardless of age. In the case of Army
early- deploying reservists, the goal of the physical and dental
examinations is to help ensure that the reservists are fit enough to be
deployed rapidly and perform their assigned jobs. Furthermore, the Army
recognizes that some jobs are more demanding than others and require more
frequent examinations. For example, the Army requires that aviators
undergo a physical examination once a year, while marine divers
and parachutists have physical examinations once every 3 years. While
governing statutes and regulations require physical examinations at
specific intervals, the Army has raised concerns about the appropriate
frequency for them. In a 1999 report to the Congress, the Offices of the
Assistant Secretaries of Defense for Health Affairs and Reserve Affairs
stated that while there were no data to support the benefits of conducting
periodic physical examinations, DOD was reluctant to recommend a
change to the statutory requirements. 17 The report stated that additional
research was needed to identify and develop a more cost- effective,
focused health assessment tool for use in conducting physical examinations
for reservists* in order to ensure the medical readiness of
reserve forces. However, as of February 2003, DOD had not conducted this
research.
For its early- deploying reservists, the Army conducts and pays for
physical and dental examinations and selected dental treatments at
military treatment facilities or pays civilian physicians and dentists to
provide these services. The Army could not provide us with information on
the cost to provide these services at military hospitals or clinics
primarily because it does not have a cost accounting system that records
or
17 Report To Congress: Means of Improving the Provision of Uniform and
Consistent Medical and Dental Care to Members of the Reserve Components
(Washington, D. C.: October 1999). Cost of Conducting
Physical and Dental Examinations and Providing Dental Treatments
Page 10 GAO- 03- 437 Assessing Health Status of Army Reservists
generates cost data for each patient. 18 However, the Army was able to
provide us with information on the amount it pays civilian providers for
these examinations under the FEDS_ HEAL program. Using FEDS_ HEAL contract
cost information, we estimate the average
cost of the examinations to be about $140 per early- deploying reservist
per year. We developed the estimate over one 5- year period by calculating
the annual cost for those early- deploying reservists requiring a physical
examination once every 5 years, calculating the cost for those requiring a
physical examination once every 2 years, and calculating the cost for
those requiring an initial dental examination and subsequent yearly dental
examinations. 19 The FEDS_ HEAL cost for each physical examination for
those under 40 is about $291, and for those over 40 is about $370. The
Army estimates that the cost of annual dental examinations under the
program to be about $80 for new patients and $40 for returning patients.
The Army estimates that it would cost from $400 to $900 per reservist to
bring those who need treatment from dental class 3 to dental class 2.
For the Army, there is likely value in conducting periodic examinations
because the average cost to provide physical and dental examinations per
early- deploying reservist* about $140 annually over a 5- year period* is
relatively low compared to the potential benefits associated with such
examinations. These examinations could help protect the Army*s investment
in its early- deploying reservists by increasing the likelihood that more
reservists will be deployable. This likelihood is increased when the Army
uses examinations to identify early- deploying reservists who do not meet
the Army*s health standards and are thus not fit for duty. The Army can
then intervene by treating, reassigning, or dismissing these reservists
with duty- limiting conditions* before their mobilization and before the
Army needs to rely on the reservists* skills or occupations. Furthermore,
by identifying duty- limiting conditions or the risks for developing them,
periodic examinations give early- deploying reservists the opportunity to
seek medical care for their conditions* prior to mobilization.
18 U. S. General Accounting Office, Department of Defense: Implications of
Financial Management Issues, GAO/ T- AIMD/ NSIAD- 00- 264 (Washington, D.
C.: July 20, 2000). 19 The average annual cost does not include allowances
for inflation, dental treatment, or specialized laboratory fees such as
those for pregnancy, phlebotomy, or tuberculosis. Benefits of Conducting
Periodic Examinations
Page 11 GAO- 03- 437 Assessing Health Status of Army Reservists
Periodic examinations may provide another benefit to the Army. If the Army
does not know the health condition of its early- deploying reservists, and
if it expects some of them to be unfit and incapable of performing their
duties, the Army may be required to maintain a larger number of reservists
than it would otherwise need in order to fulfill its military and
humanitarian missions. While data are not available to estimate these
benefits, the benefit associated with reducing the number of reservists
the Army needs to maintain for any given objective could be large enough
to more than offset the cost of the examinations and treatments. The
proportion of reservists whom the Army maintains but who cannot be
deployed because of their health may be significant. For instance,
according to a 1998 U. S. Army Medical Command study, a *significant
number* of Army reservists could not be deployed for medical reasons
during mobilization for the Persian Gulf War (1990- 1991). 20 Further,
according to a study by the Tri- Service Center for Oral Health Studies at
the Uniformed Services University of the Health Sciences, an estimated 25
percent of Army reservists who were mobilized in response to the events
of September 11, 2001, were in dental class 3 and were thus undeployable.
21 In fact, our analysis of the available current dental examinations at
the seven early- deploying units showed a similar percentage of
reservists* 22 percent* who were in dental class 3. 22 With each
undeployable reservist, the Army loses, at least temporarily, a
significant investment that is large compared to the cost of examining and
treating these reservists. The annual salary for an Army early- deploying
reservist in fiscal year 2001 ranged from $2,200 to $19,000. The Army
spends additional amounts to train and equip each reservist and, in some
cases, provides allowances for subsistence and housing. Additionally, for
each reservist it mobilizes, the Army spends about $800. 23 If it does not
examine all of its early- deploying reservists, the Army risks losing its
20 The U. S. Army Medical Command*s: Reserve Component 746 Study, (June
22, 1998), provides no specific number stating only that a *significant
number* could not be deployed. 21 This study included reservists from the
U. S. Army Reserve but not reservists from the Army National Guard.
22 Twenty- two dental examinations listed early- deploying reservists in
class 3 out of 101 current (within 1 year) dental examinations. Additional
examinations that were available for our review were either out of date or
conducted by nondental personnel. 23 U. S. General Accounting Office,
Reserve Forces: Cost, Funding, and Use of Army Reserve Components in
Peacekeeping Operations, GAO/ NSAID- 98- 190R (Washington, D. C.: May 15,
1998).
Page 12 GAO- 03- 437 Assessing Health Status of Army Reservists
investment because it will train, support, and mobilize reservists who
might not be deployed because of their health.
The Army has not consistently carried out the requirements that
earlydeploying reservists undergo 5- or 2- year physical examinations, and
the required dental examination. In addition, the Army has not required
earlydeploying reservists to complete the annual medical certificate of
their health condition, which provides the basis for the required annual
medical screening. Accordingly, the Army does not have current health
information on early- deploying reservists. Furthermore, the Army does not
have the ability to maintain information from medical and dental records
and annual medical certificates at the aggregate or individual level, and
therefore does not know the overall health status of its early- deploying
reservists.
We found that the Army has not consistently met the statutory requirements
to provide early- deploying reservists physical examinations at 5- or 2-
year intervals. At the seven Army early- deploying reserve units we
visited, about 66 percent of the medical records were available for our
review. 24 Based on our review of these records, 13 percent of the
reservists
did not have a current 5- year physical examination on file. Further, the
Army is also required to provide physical examinations every 2 years for
Army early- deploying reservists over the age of 40. However, our review
of the available records found that approximately 68 percent of
earlydeploying reservists over age 40 did not have a record of a current
biennial examination. Army early- deploying reservists are required by
statute to complete an
annual medical certificate of their health status, and regulations require
the Army to review the form to satisfy the annual screening requirement.
In performing our review of the records on hand, we found that none of the
units we visited required that its reservists complete the annual medical
certificate, and consequently, none of them were available for review.
Furthermore, Army officials stated that reservists at most other
24 There were 504 early- deploying reservists assigned to the seven units
we visited. Medical records for 332 reservists were available for our
review. Army administrators told us that the remaining files were in
transit, with the reservist, or on file at another location. The Army Has
Not Collected and
Maintained All Required Medical and Dental Information on Early- Deploying
Reservists
Examinations Have Not Always Been Performed and Annual Medical
Certificates Have Not Been Completed and Reviewed
Page 13 GAO- 03- 437 Assessing Health Status of Army Reservists
units have not filled out the certification form and that enforcement of
this requirement was poor.
The Army is also statutorily required to provide early- deploying
reservists with an annual dental examination to establish whether
reservists meet the dental standards for deployment. At the seven early-
deploying units that we visited, we found that about 49 percent of the
reservists whose records were available for review did not have a record
of a current dental examination. The Army*s two automated information
systems for monitoring reservists*
health do not maintain important medical and dental information for
earlydeploying reservists* including information on the early- deploying
reservists* overall health status, information from the annual medical
certificate form, dental classifications, and the date of dental
examinations. In one system, the Regional Level Application Software, the
records provide information on the dates of the 5- year physical
examination and the physical profile ratings. In the other system, the
Medical Occupational Database System, the records provide information on
HIV status, immunizations, and DNA specimens. Neither system allows the
Army to review medical and dental information for entire units at an
aggregate level. The Army is aware of the information shortcomings of
these systems and acknowledges that having sufficient, accurate, and
current information on the health status of reservists is critical for
monitoring combat readiness. According to Army officials, in 2003 the Army
plans to expand the Medical Occupational Database System to provide the
Army with access to current, accurate, and relevant medical and dental
information at the aggregate and individual levels for all of its
reservists* including early- deploying reservists. According to Army
officials, this information will be readily available to the U. S. Army
Reserve Command. Once available, the Army can use this information to
determine which early- deploying reservists meet the Army*s health care
standards and are ready for deployment.
Army reservists have been increasingly called upon to serve in a variety
of operations, including peacekeeping missions and the current war on
terrorism. Given this responsibility, periodic health examinations are
important to help ensure that Army early- deploying reservists are fit for
deployment and can be deployed rapidly to meet humanitarian and wartime
needs. However, the Army has not fully complied with statutory
requirements to assess and monitor the medical and dental status of early
Army*s Automated
Systems Do Not Contain Comprehensive Health Information on EarlyDeploying
Reservists
Conclusions
Page 14 GAO- 03- 437 Assessing Health Status of Army Reservists
deploying reservists. Consequently, the Army does not know how many of
them can perform their assigned duties and are ready for deployment.
The Army will realize benefits by fully complying with the statutory
requirements. The information gained from periodic physical and dental
examinations, coupled with age- specific screenings and information
provided by early- deploying reservists on an annual basis in their
medical certificates, will assist the Army in identifying potential duty-
limiting medical and dental problems within its reserve forces. This
information will help ensure that early- deploying reservists are ready
for their deployment duties. Given the importance of maintaining a ready
force, the benefits associated with the relatively low annual cost of
about $140 to conduct these examinations outweighs the thousands of
dollars spent in salary and training costs that are lost when an early-
deploying reservist is not fit for duty.
The Army*s planned expansion, in 2003, of an automated health care
information system is critical for capturing the key medical and dental
information needed to monitor the health status of early- deploying
reservists. Once collected, the Army will have additional information to
conduct the research suggested by DOD*s Offices of Health Affairs and
Reserve Affairs to determine the most effective approach, which could
include the frequency of physical examinations, for determining whether
early- deploying reservists are healthy, can perform their assigned
duties, and can be rapidly deployed.
To help ensure that early- deploying reservists are healthy to carry out
their duties, we recommend that the Secretary of Defense direct the
Secretary of the Army to comply with existing statutory requirements to
ensure that the 5- year physical examinations for early- deploying
reservists under 40
and the biennial physical examinations for early- deploying reservists
over 40 are current and complete, all early- deploying reservists
complete their annual medical certificate of
health status and that the appropriate Army personnel review the
certificate, and the required dental examinations and treatments for all
early- deploying
reservists are complete. Recommendations for Executive Action
Page 15 GAO- 03- 437 Assessing Health Status of Army Reservists
The Department of Defense provided written comments on a draft of this
report, which are found in appendix IV. DOD concurred with the report*s
recommendations.
DOD raised some concerns about our evaluation. For example, DOD stated
that the intermittent use of the terms *The Army,* *Reserve Component,*
and *Army Reserve* would lead to a misunderstanding of the organization of
Army Components. While DOD did not offer specific examples, we reviewed
the draft to ensure that terms were used appropriately and did not make
any changes. DOD also raised the concern that we used a very narrow
subject group that may not reflect a valid representative sample and that
the report findings could be incorrectly applied to the Army National
Guard. As we noted in our draft report, our work was conducted at seven
early deploying U. S. Army Reserve units* geographically dispersed in the
states of Georgia, Maryland, and Texas* and our analysis of the
information collected at these units is not projectable. Finally, DOD
stated that methods for annually certifying physical conditions could also
include completing the statement of physical condition that is preprinted
on the Personnel Qualification Record, and that we did not consider
whether such alternatives were used for certification. During our visits
we reviewed the medical files at all locations, the personnel files at one
location, and interviewed military personnel who were responsible for
maintaining the records of earlydeploying reservists at all locations. We
were unable to find one annual medical certificate that was reviewed by
military personnel to meet the statutory requirements. In addition, some
military personnel were not aware of the requirement.
We are sending copies of this report to the Secretary of Defense,
appropriate congressional committees, and other interested parties. Copies
will also be made available to others on request. In addition, the report
is available at no charge on the GAO Web site at Agency Comments
and Our Evaluation
Page 16 GAO- 03- 437 Assessing Health Status of Army Reservists
http:// www. gao. gov. If you or your staff have any questions about this
report, please contact me at (202) 512- 7101. Another contact and major
contributors are listed in appendix V. Marjorie E. Kanof
Director, Health Care* Clinical and Military Health Care Issues
Page 17 GAO- 03- 437 Assessing Health Status of Army Reservists
List of Committees
The Honorable John Warner Chairman The Honorable Carl Levin Ranking
Minority Member Committee on Armed Services United States Senate
The Honorable Ted Stevens Chairman The Honorable Daniel K. Inouye Ranking
Minority Member Subcommittee on Defense Committee on Appropriations United
States Senate
The Honorable Duncan Hunter Chairman The Honorable Ike Skelton Ranking
Minority Member Committee on Armed Services House of Representatives
The Honorable Jerry Lewis Chairman The Honorable John P. Murtha Ranking
Minority Member Subcommittee on Defense Committee on Appropriations House
of Representatives
Appendix I: Scope and Methodology Page 18 GAO- 03- 437 Assessing Health
Status of Army Reservists
We reviewed statutes and Army policies and regulations governing annual
medical and dental screenings, and periodic physical and dental
examinations. We obtained data from the Office of the Chief, U. S. Army
Reserve on the physical and dental examinations performed since 2001 on
early- deploying reservists. We reviewed our past reports that addressed
medical and dental examinations. We conducted site visits to seven U. S.
Army Reserve Units located in Georgia, Maryland, and Texas* where we
obtained and reviewed all available medical and dental records. There were
504 early- deploying reservists assigned to the seven units we visited.
Medical records for 332 reservists were available for our review. Army
administrators told us that the remaining files were in transit, with the
reservist, or on file at another location. Our analysis of the information
gathered at these units is not projectable. We did not review medical or
dental records at Army National Guard units, but obtained information from
the Guard on its medical policies.
To calculate an average annual cost to provide physical and dental
examinations for Army early- deploying reservists, we obtained estimates
from the Army*s Federal Strategic Healthcare Alliance (FEDS_ HEAL)
administrator on the costs of outsourcing the examinations. We calculated
the annual cost for those reservists requiring a physical examination once
every 5 years and those requiring a physical examination once every 2
years. In developing the annual cost estimate, we used DOD information on
the number of Army reservists that are under 40 (approximately 75
percent), and those over 40 (approximately 25 percent). We also included
the initial dental examination cost and subsequent yearly dental
examination costs. All costs were averaged over one 5- year period. The
average annual cost does not include allowances for inflation, dental
treatment, or specialized laboratory fees such as those for pregnancy,
phlebotomy, and tuberculosis. We also obtained estimates of the cost to
perform dental treatments from the Army Office of the Surgeon General and
Army Dental Command.
We obtained from DOD, HHS*s Office of Public Health and Science, the
Centers for Disease Control and Prevention, medical associations, and
dental associations studies and information concerning the advisability of
periodic physical and dental examinations. From these organizations we
also obtained published common practices and standards concerning periodic
medical and dental examinations, age and risk factors, and the value and
relevance of patients* self- reporting of symptoms. Appendix I: Scope and
Methodology
Appendix II: Army Physical Profile Rating Guide Page 19 GAO- 03- 437
Assessing Health Status of Army Reservists
Assessment areas Physical profile rating Physical
capacity Upper extremities Lower
extremities Hearing- ears Vision- eyes Psychiatric
Organic defects, strength, stamina, agility, energy, muscular
coordination, function, and similar factors. Strength, range
of motion, and general efficiency of upper arm, shoulder girdle, and upper
back, including cervical and thoracic vertebrae.
Strength, range of movement, and efficiency of feet, legs, lower back, and
pelvic girdle.
Auditory sensitivity and organic disease of the ears.
Visual acuity and organic disease of the eyes and lids.
Type, severity, and duration of the psychiatric
symptoms or disorder existing at the time the
profile is determined. Amount of external precipitating
stress. Predispositions as determined by
the basic personality makeup, intelligence, performance, and history of
past psychiatric disorder impairment of functional capacity. P1 (Non-
duty- limiting conditions)
Good muscular development with ability to perform maximum effort for
indefinite
periods. No loss of digits or limitation of
motion; no demonstrable abnormality; able to do hand- tohand fighting.
No loss of digits or limitation of motion; no demonstrable abnormality;
able to perform long marches, stand over long periods, and run.
Audiometer average level for each ear not more than 25 dB 1 at 500, 1000,
or 2000 Hz 2 with no
individual level greater than 30 dB. Not over 45 dB at 4000 Hz.
Uncorrected vision acuity 20/ 200 correctable to 20/ 20 in each eye.
No psychiatric pathology; may have history of
transient personality disorder.
1 dB (decibels), the decibel is a measure of the intensity of sound. 2 Hz
(Hertz), the Hertz is the measure of sound frequency or pitch. Appendix
II: Army Physical Profile Rating
Guide
Appendix II: Army Physical Profile Rating Guide Page 20 GAO- 03- 437
Assessing Health Status of Army Reservists
Assessment areas Physical profile rating Physical
capacity Upper extremities Lower
extremities Hearing- ears Vision- eyes Psychiatric
P2 (Non- dutylimiting
conditions) Able to perform
maximum effort over long periods. Slightly limited
mobility of joints, muscular weakness, or other musculoskeletal defects
that do not
prevent hand- tohand fighting and do not disqualify for prolonged effort.
Slightly limited mobility of joints, muscular weakness, or other
musculoskeletal defects that do not
prevent moderate marching, climbing, timed walking, or
prolonged effort. Audiometer
average level for each ear at 500, 1000, or 2000 Hz, not more than 30 dB,
with no individual level greater than 35 dB at these frequencies, and
level not more than 55 dB at 4000 Hz; or audiometer level 30 dB at 500 Hz,
25 dB at 1000 and 2000 Hz, and 35 dB at 4000 Hz in better ear. (Poorer ear
may be deaf.)
Distant visual acuity correctable to not worse than 20/ 40 and 20/ 70, or
20/ 30 and 20/ 100, or 20/ 20 and 20/ 400.
May have history of recovery from an acute psychotic reaction due to
external or toxic
causes unrelated to alcohol or drug addiction.
P3 (Duty- limiting conditions)
Unable to perform full effort except for brief or moderate periods.
Defects or impairments that require significant
restriction of use. Defects or
impairments that require significant
restriction of use. Speech
reception threshold in best ear not greater than 30 dB HL 3 measured with
or
without hearing aid, or chronic ear disease.
Uncorrected distant visual acuity of any degree that is correctable to not
less than 20/ 40 in the better eye.
Satisfactory remission from an acute psychotic or neurotic episode that
permits
utilization under specific conditions (assignment when outpatient
psychiatric
treatment is available or certain duties can be avoided). P4 (Duty-
limiting conditions)
Functional level below P3. Functional level
below P3. Functional level below P3. Functional level
below P3. Functional level below P3. Functional level
below P3. Source: Army.
Note: Army Regulation 40- 501, Mar. 28, 2002. 3 HL (hearing loss).
Appendix III: Annual Medical Certificate Page 21 GAO- 03- 437 Assessing
Health Status of Army Reservists
Appendix III: Annual Medical Certificate
Appendix III: Annual Medical Certificate Page 22 GAO- 03- 437 Assessing
Health Status of Army Reservists
Appendix IV: Comments from the Department of Defense
Page 23 GAO- 03- 437 Assessing Health Status of Army Reservists
Appendix IV: Comments from the Department of Defense
Appendix IV: Comments from the Department of Defense
Page 24 GAO- 03- 437 Assessing Health Status of Army Reservists
Appendix IV: Comments from the Department of Defense
Page 25 GAO- 03- 437 Assessing Health Status of Army Reservists
Appendix IV: Comments from the Department of Defense
Page 26 GAO- 03- 437 Assessing Health Status of Army Reservists
Appendix V: GAO Contact and Staff Acknowledgments
Page 27 GAO- 03- 437 Assessing Health Status of Army Reservists
Michael T. Blair, Jr., (404) 679- 1944 The following staff members made
key contributions to this report: Aditi S. Archer, Richard J. Wade,
Krister P. Friday, Helen T. Desaulniers, and Mary W. Reich. Appendix V:
GAO Contact and Staff
Acknowledgments GAO Contact Acknowledgments
Related GAO Products Page 28 GAO- 03- 437 Assessing Health Status of Army
Reservists
Military Personnel: Preliminary Observations Related to Income, Benefits,
and Employer Support for Reservists During Mobilizations.
GAO- 03- 549T. Washington, D. C.: March 19, 2003. Defense Health Care:
Most Reservists Have Civilian Health Coverage but More Assistance Is
Needed When TRICARE Is Used. GAO- 02- 829. Washington, D. C.: September 6,
2002.
Reserve Forces: DOD Actions Needed to Better Manage Relations between
Reservists and Their Employers. GAO- 02- 608. Washington, D. C.: June 13,
2002.
Department of Defense: Implications of Financial Management Issues.
GAO/ T- AIMD/ NSIAD- 00- 264. Washington, D. C.: July 20, 2000. Reserve
Forces: Cost, Funding, and Use of Army Reserve Components in Peacekeeping
Operations. GAO/ NSAID- 98- 190R. Washington, D. C.: May 15, 1998.
Defense Health Program: Future Costs Are Likely to Be Greater than
Estimated. GAO/ NSIAD- 97- 83BR. Washington, D. C.: February 21, 1997.
Wartime Medical Care: DOD Is Addressing Capability Shortfalls, but
Challenges Remain. GAO/ NSIAD- 96- 224. Washington, D. C.: September 25,
1996.
Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet Medical and
Physical Fitness Standards. GAO/ NSIAD- 94- 36. Washington, D. C.: March
23, 1994.
Operation Desert Storm: Problems With Air Force Medical Readiness.
GAO/ NSIAD- 94- 58. Washington, D. C.: December 30, 1993.
Reserve Components: Factors Related to Personnel Attrition in the Selected
Reserve. GAO/ NSIAD- 91- 135. Washington, D. C.: April 8, 1991. Related
GAO Products
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