VA and DOD Health Care: Efforts to Coordinate a Single Physical  
Exam Process for Servicemembers Leaving the Military (12-NOV-04, 
GAO-05-64).							 
                                                                 
Servicemembers who leave the military and file disability claims 
with the Department of Veterans Affairs (VA) may be subject to	 
potentially duplicative physical exams in order to meet 	 
requirements of both the Department of Defense's (DOD) military  
services and VA. To streamline the process for these		 
servicemembers, the military services and VA have attempted to	 
coordinate their physical exam requirements by developing a	 
single separation exam program. In 1998, VA and DOD signed a	 
memorandum of understanding (MOU) instructing local units to	 
establish single separation exam programs. This report examines  
(1) VA's and the military services' efforts to establish single  
separation exam programs, and (2) the challenges to establishing 
single separation exam programs. To obtain this information, GAO 
interviewed VA and military service officials about establishing 
the program; evaluated existing programs at selected military	 
installations; and visited selected installations that did not	 
have programs.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-64						        
    ACCNO:   A13552						        
  TITLE:     VA and DOD Health Care: Efforts to Coordinate a Single   
Physical Exam Process for Servicemembers Leaving the Military	 
     DATE:   11/12/2004 
  SUBJECT:   Claims processing					 
	     Disabilities					 
	     Health care programs				 
	     Interagency relations				 
	     Medical examinations				 
	     Military personnel 				 
	     Program evaluation 				 
	     Veterans benefits					 
	     Veterans disability compensation			 
	     VA/DOD Benefits Delivery at Discharge		 
	     Program						 
                                                                 

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GAO-05-64

United States Government Accountability Office

GAO

                       Report to Congressional Requesters

November 2004

VA AND DOD HEALTH CARE

Efforts to Coordinate a Single Physical Exam Process for Servicemembers Leaving
                                  the Military

GAO-05-64

[IMG]

November 2004

VA AND DOD HEALTH CARE

Efforts to Coordinate a Single Physical Exam Process for Servicemembers Leaving
the Military

What GAO Found

Since 1998, VA and the military services have collaborated to establish
single separation exam programs. However, while we were able to verify
that the program was being delivered at some military installations, DOD,
its military services, and VA either could not provide information on
program locations or provided us with inaccurate information. As of May
2004, VA reported that 28 military installations had single separation
exam programs that used one of five basic approaches to deliver an exam
that met both VA's and the military services' requirements. However, when
we evaluated 8 of the 28 installations, we found that 4 of the
installations did not actually have programs in place. Nonetheless, VA and
DOD leadership continue to encourage the establishment of single
separation exam programs and have recently drafted a new memorandum of
agreement (MOA) that is intended to replace the 1998 MOU. Like the
original MOU, the draft MOA delegates responsibility for establishing
single separation exam programs to local VA and military installations,
depending on available resources. However, the draft MOA also contains a
specific implementation goal that selected military installations should
have single separation exam programs in place by December 31, 2004. This
would require implementation at 139 installations-an ambitious plan given
the seemingly low rate of program implementation since 1998 and the lack
of accurate information on existing programs.

Several challenges impede the establishment of single separation exam
programs. The predominant challenge is that the military services may not
benefit from a program designed to eliminate the need for two separate
physical exams because they usually do not require that servicemembers
receive a separation exam. As of August 2004, only the Army had a general
separation exam requirement for retiring servicemembers. The other
military services primarily require separation exams when the
servicemember's last physical exam or medical assessment received during
active duty is no longer considered current. In fiscal year 2003, only an
estimated 13 percent of servicemembers who left the military received a
separation exam. Consequently, the military services may not realize
resource savings by eliminating or sharing responsibility for this exam.
According to some military officials, another challenge to establishing
single separation exam programs is that resources, such as facility space
and medical personnel, are needed for other priorities, such as ensuring
that active duty servicemembers are healthy enough to perform their
duties. Additionally, because single separation exam programs require
coordination between personnel from both VA and the military services,
military staff changes, including those due to routine rotations, can make
it difficult to maintain existing programs.

                 United States Government Accountability Office

Contents

Letter

Results in Brief
Background
VA and the Military Services Have Established Some Single

Separation Exam Programs, But Program Monitoring Is Lacking
Despite Plans for Expansion

Infrequent Use of Separation Exams Among Military Services and
Other Factors Create Challenges in Establishing Single
Separation Exam Programs

Conclusions
Recommendations for Executive Action
Agency Comments

                                       1

                                      3 5

11

16 20 20 20

Appendix I Scope and Methodology

Appendix II DOD's Form 2697 - Report of Medical Assessment

Appendix III DOD's Form 2808 - Report of Medical Examination

Appendix IV	Comments from the Department of Veterans Affairs
and GAO's Response 30

GAO Comments 35

Appendix V Comments from the Department of Defense

Appendix VI GAO Contacts and Staff Acknowledgments 38

GAO Contacts 38
Acknowledgments 38

Tables

Table 1: Individual Military Service Requirements for Evaluating
Servicemembers' Health 7 Table 2: Approaches Used to Deliver Single
Separation Exams at Selected Military Installations 12 Table 3:
Installations That VA Incorrectly Reported as Having Single Separation
Exam Programs 13

Figure

Figure 1: Estimated Percentage of Servicemembers Who Received Separation
Exams in Fiscal Year 2003

Abbreviations

AFEB Armed Forces Epidemiology Board
BDD Benefits Delivery at Discharge
C&P compensation and pension
DMDC Defense Manpower Data Center
DOD Department of Defense
MOA memorandum of agreement
MOU memorandum of understanding
PHA preventive health assessment
VA Department of Veterans Affairs

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separately.

United States Government Accountability Office Washington, DC 20548

November 12, 2004

The Honorable Duncan Hunter
Chairman
Committee on Armed Services
House of Representatives

The Honorable Christopher H. Smith
Chairman
Committee on Veterans' Affairs
House of Representatives

Servicemembers who leave the military and file disability claims with the
Department of Veterans Affairs (VA) may be subject to potentially
duplicative physical exams in order to meet requirements of both the
Department of Defense's (DOD) military services and VA.1 VA requires
servicemembers applying for service-connected disability compensation to
undergo a physical exam, known as a compensation and pension (C&P)
exam, in order to determine the degree of their disability. During fiscal
year 2003, about 55,500 veterans submitted disability claims to VA within
their first year of leaving the military. Similarly, to document any
potential
service-related health conditions or complaints of servicemembers leaving
the military, each of the military services requires a medical assessment,
which consists of a questionnaire and in some cases may include a
physical exam. Moreover, each military service has additional medical
requirements servicemembers must meet when they leave the military-
requirements that in some cases include a physical exam, also known as a
separation exam. In fiscal year 2003, about 176,000 servicemembers left
the military and were subject to applicable requirements.

Although the purpose and scope of the physical exams administered by
the military services differ from those administered by VA, the military
services and VA developed a way to coordinate their physical exam
requirements, prevent duplication, and streamline the process for
servicemembers who are leaving the military and filing disability claims.
In
1994, VA and the Army initiated a multiyear pilot program that concluded

1The branches of DOD's uniformed military services (military services)
discussed in this report are the Army, the Navy, the Air Force, and the
Marines.

that a program consisting of one physical exam could be designed to meet
both the military services' requirements for servicemembers leaving the
military and VA's requirements for determining disability. VA and the Army
also concluded that such a program would encourage a more efficient use of
VA and military resources, improve the timeliness of disability claims
processing, and offer convenience to servicemembers. Based on the findings
of the pilot program, in 1998, VA's Under Secretary for Health and DOD's
Acting Assistant Secretary of Defense for Health Affairs signed a
memorandum of understanding (MOU) that directed local VA offices and
military medical facilities to work together to establish single
separation exam programs.

To target servicemembers who are preparing to leave the military and
intend to file a disability claim, VA is working with the military
services to establish single separation exam programs at military
installations that have a Benefits Delivery at Discharge (BDD) program.
The BDD program is a joint VA/DOD initiative designed to streamline
servicemembers' transition from active duty to veterans' status. At
military installations with BDD programs, VA personnel educate
servicemembers about VA disability benefits and help them apply for
benefits before they leave military service-a process that is otherwise
initiated after servicemembers leave the military. BDD programs, which are
designed for servicemembers who have between 60 and 180 days remaining on
active duty, are usually located at military installations that have large
numbers of servicemembers leaving the military. At BDD sites that have
single separation exam programs, servicemembers typically receive a single
separation exam after they submit their disability claims paperwork. As of
August 2004, VA reported there were BDD programs at 139 military

2

installations.

You asked us to provide information on how VA and DOD's military services
are collaborating to provide single separation exams for servicemembers
who leave the military and intend to apply for serviceconnected disability
compensation.3 This report examines (1) VA's and the

2We did not verify information related to the BDD program sites because it
was outside the scope of our work.

3This request also asked for information, which is addressed in a separate
GAO report, 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). This report provides
information on the military services' implementation of DOD's health
protection and surveillance policies for servicemembers deployed to Iraq
in support of Operation Iraqi Freedom.

                    military services' efforts to establish single separation 
                                                           exam programs, and 
                    (2) the challenges to establishing single separation exam 
                    programs.                                                 
                    To identify VA's and the military services' efforts to    
                    establish single                                          
                    separation exam programs, we obtained information on VA's 
                    and the                                                   
                            military services' medical requirements involving 
                                                      physical exams or other 
                    medical evaluations, and we interviewed officials from    
                    the Office of the                                         
                    Assistant Secretary of Defense for Health Affairs, the    
                    military services'                                        
                         Surgeons General, and VA. We also obtained a list of 
                                                       military installations 
                            that VA reported as having single separation exam 
                                                       programs. We used this 
                    list to select eight installations that represented each  
                    branch of the                                             
                           military services to further evaluate VA's and the 
                                                   military services' efforts 
                    to establish these programs. We did not verify whether    
                    the remaining                                             
                    installations on VA's list had operational programs in    
                    place, and we are                                         
                    only reporting on how programs were operating at these    
                    eight selected                                            
                    installations. To identify the challenges to establishing 
                                                            single separation 
                    exam programs, we interviewed VA officials from 15        
                    locations whose                                           
                    regions included military installations with at least 500 
                    servicemembers                                            
                    who left the military in fiscal year 2003.4 We also       
                    visited seven military                                    
                             installations that were not administering single 
                                                     separation exam programs 
                    to learn why such programs were not in place. These seven 
                                                                installations 
                      represented each of the military services and had at    
                                            least 500                         
                       servicemembers leaving the military during fiscal year 
                                                           2003. In addition, 
                          we obtained data on the number of disability claims 
                                                         filed, the number of 
                       separations from the military, the estimated number of 
                                                             separation exams 
                    provided by the military services, and the average costs  
                    of VA and DOD                                             
                    physical exams. We assessed the reliability of these data 
                                                               and determined 
                    that they were sufficiently reliable for our purposes.    
                    Our work was                                              
                         performed from January 2004 through November 2004 in 
                                                              accordance with 
                    generally accepted government auditing standards. For     
                    more details on                                           
                           our scope and methodology, see appendix I.         
                                Since 1998, VA and the military services have 
Results in Brief          collaborated to establish single separation exam 
                              programs. However, while we were able to verify 
                        that the program was being delivered at some military 
                                                          installations, DOD, 
                    its military services, and VA either could not provide    
                    information on                                            

4We selected one additional region with a military installation where less
than 500 servicemembers left the military in fiscal year 2003 because VA
reported that in this region VA physicians were delivering single
separation exams at a VA medical center, a different approach than that
reported by our other selected sites.

program locations or provided us with inaccurate information. As of May
2004, VA reported that 28 of 139 military installations with BDD programs
also had single separation exam programs that used one of five basic
approaches to deliver an exam that met both VA's and the military
services' requirements. However, when we evaluated 8 of the 28
installations, we found that 4 of the installations did not actually have
programs in place. Nonetheless, VA and DOD leadership continue to
encourage the establishment of single separation exam programs and have
recently drafted a new memorandum of agreement (MOA) that is intended to
replace the 1998 MOU. Like the original MOU, the draft MOA delegates
responsibility for establishing single separation exam programs to local
VA and military installations, depending on available resources. However,
the draft MOA also contains a specific implementation goal that all BDD
sites should have single separation exam programs in place by December 31,
2004-an ambitious plan given the seemingly low rate of program
implementation since 1998 and the lack of accurate information on existing
programs.

Several challenges impede the establishment of single separation exam
programs. The predominant challenge is that the military services may not
benefit from a program designed to eliminate the need for two separate
physical exams because they usually do not require that servicemembers
receive a separation exam. As of August 2004, only the Army had a general
separation exam requirement for retiring servicemembers. The other
military services primarily require separation exams when the
servicemember's last physical exam or medical assessment received during
active duty is no longer considered current. In fiscal year 2003, only an
estimated 13 percent of servicemembers who left the military received a
separation exam. Consequently, the military services may not realize
resource savings by eliminating or sharing responsibility for this exam.
According to some military officials, another challenge to establishing
single separation exam programs is that resources, such as facility space
and medical personnel, are needed for other priorities, such as ensuring
that active duty servicemembers are healthy enough to perform their
duties. Additionally, because single separation exam programs require
coordination between personnel from both VA and the military services,
military staff changes, including those due to routine rotations, can make
it difficult to maintain existing programs.

We are making a recommendation that the Secretary of VA and the Secretary
of Defense develop systems to monitor and track the progress of VA
regional offices and military installations in implementing single
separation exam programs at BDD sites. In commenting on a draft of this

Background

report, VA and DOD concurred with the report's findings and
recommendation.

The military services and VA have medical requirements that servicemembers
must meet when leaving the military and applying for VA disability
compensation. These requirements include a medical assessment; a
service-specific separation exam, which is given to some servicemembers;
and a VA C&P exam. The single separation exam program is designed to
provide a single physical exam that can be used to meet the physical exam
requirements of the military services and VA.

The Military Services' Requirements for Medical Assessments and Separation
Exams

In response to a 1994 memorandum from the Assistant Secretary of Defense
for Health Affairs, all of the military services require a medical
assessment of all servicemembers leaving the military, including those
that retire or complete their tour of active duty.5 This assessment, which
is used to evaluate and document the health of these servicemembers,
consists of a standard two-page questionnaire asking servicemembers about
their overall health, medical and dental histories, current medications,
and other health-related topics.6 (See app. II for DOD's medical
assessment form-DD Form 2697.) Military medical personnel, who could
include a physician, a physician's assistant, or a nurse practitioner, are
required to review the questionnaire with the servicemember. If the
questionnaire indicates the presence of an illness, injury, or other
medical problem, the reviewer is required to ensure that the
servicemember's medical or dental records document the problem. In
addition, depending on the servicemember's responses or based on the
reviewer's judgment that additional information is needed, the health
assessment could result in a physical exam-one focused on a particular

5Servicemembers who retire from the military are eligible for retirement
benefits including healthcare and a pension as well as VA benefits. Those
who are separating because their tour of duty is complete are only
eligible for VA benefits. Of the servicemembers who left the military in
fiscal year 2003, 22 percent were retirees and 34 percent had completed
their tours of active duty. The remaining 44 percent were discharged for
other reasons, such as illness or because they were unable to fulfill
their military duties.

6DOD's action and the development of DD Form 2697 were completed in
response to direction from the House Committee on Armed Services in 1993
to implement a departmentwide policy, by regulation, for each
servicemember to receive a comprehensive medical interview before
separating from active duty, as well as a comprehensive physical
evaluation upon identification of complaints, illnesses, or injuries. See
H.R. No. 103-200, at 304-305 (1993) (accompanying H.R. 2401, National
Defense Authorization Act for Fiscal Year 1994). DOD itself did not issue
regulations, but directed each military service to do so.

health issue or issues in order to supplement information disclosed on the
questionnaire. Furthermore, the medical assessment asks if the
servicemember intends to file a claim for disability with VA.
Servicemembers who answer "yes" on the assessment form will be given a
clinically appropriate assessment or exam if the servicemember's last
physical exam received during active duty is more than 12 months old or if
new symptoms have appeared since the last active duty exam.7

In addition, the Army, Navy, Air Force, and Marines8 require some of their
servicemembers to undergo separation exams when they leave the military.
Separation exams consist of a clinical evaluation by a medical provider
and could include various diagnostic tests, such as a urinalysis, a
hearing test, and a vision test. Separation exams, as well as other
physical exams the military services conduct, are documented on a
three-page standard DOD form. (See app. III for DOD's report of medical
examination-DD Form 2808.) According to DOD, the average cost for a
physical exam given by the military services is about $125, exclusive of
any diagnostic tests that may also be conducted.9

The requirements determining which servicemembers must receive separation
exams vary by military service and other factors. The Army requires that
its retirees receive separation exams, although the Army does not usually
require this for servicemembers who are completing their tours of active
duty. The other military services do not require separation exams for most
servicemembers, except for those whose last physical exam or assessment
they received during active duty is out of date. (See table 1 for each
military service's medical evaluation requirements.) Further, all of the
military services also require separation exams for certain occupational
specialties. For example, the military services require separation exams
for servicemembers who have worked with hazardous materials. Finally, any
servicemember can request and receive a separation exam.

7The Ronald W. Reagan National Defense Authorization Act of 2005 requires
certain members of the armed forces to undergo a separation physical
examination unless such members have had such an examination within 12
months and a waiver is granted with the member and the member's unit
commander's consent. See Pub. L. No. 108-375, S: 706(b), 118 Stat. 1773,
(amending 10 U.S. C. S: 1145(a)).

8The Marines follow the Navy's requirements.

9DOD's cost data do not distinguish between separation exams and other
types of physical exams.

Table 1: Individual Military Service Requirements for Evaluating
Servicemembers' Health

Military During active duty   Completion of active duty      Retirement    
service          a                      tour              
              Physical exams     Separation exams are not    Separation exams 
     Army         occur                   usually              are mandatory. 
            every 5 years                required.           
            beginning at                                     
            age 30, and                                      
            annually for                                     
            those age 60 and                                 
            older.                                           

Navy/Marines 	Physical exams occur Separation exams are not usually
Separation exams are not usually every 5 years through age required unless
a servicemember does required unless a servicemember does 50, every 2
years through not have a current physical exam on file.b not have a
current physical exam on file.b

age 60, and annually after If a current exam is on file,b the Navy If a
current exam is on file,b the Navy

age 60. 	requires a review of the servicemember's requires a review of the
servicemember's medical history, documentation of any medical history,
documentation of any changes in health, and a focused exam, if changes in
health, and a focused exam, needed. if needed.

Air Force 	Preventive Health A separation assessment is required A
separation assessment is required Assessments (PHA)c occur when the
servicemember has not had a when the servicemember has not had a annually.
PHA within the last year. PHA within the last year.

A separation exam is required if the A separation exam is required if the
servicemember has not had a PHA within servicemember has not had a PHA
within

dd

5 years of scheduled separation. 3 years of scheduled separation.

Sources: GAO analyses of Army Regulation 40-501, Chapter 8 (2/19/04);
Virtual Naval Hospital, Manual of the Medical Department, NAVMED P-117
(8/20/02); and Air Force Instruction 48-123 (5/22/01).

aIn addition to these general active duty requirements, each military
service has specific requirements based on factors such as gender and
occupational specialty.

bThe time period after which an exam is considered not current can vary
for different servicemembers.

cDuring a PHA, medical providers check for evidence of disease and
preventable illnesses using information from each servicemember's past
medical history, lifestyle, age, sex, hazards in the workplace, and
medical threats related to deployment.

dAccording to DOD officials, the Air Force's separation exams are only
required in the rare instance that servicemembers miss their annual
assessments.

Requirements for separation exams may be affected by planned changes to
physical exam requirements for active duty servicemembers. The Army and
Navy plan to change their physical exam requirements for servicemembers
during active duty-replacing routine physical exams with periodic health
assessments, thereby moving closer to the Air Force's requirements for
active duty servicemembers. In September 2003, the Armed Forces
Epidemiology Board (AFEB)10 issued a report that concluded that annual
health assessments, as currently administered by

10The AFEB is a scientific advisory body to the Assistant Secretary of
Defense for Health Affairs and the services' Surgeons General. It provides
scientific and professional advice concerning operational programs, policy
development, and research needs for the prevention of disease and injury
and the promotion of health.

the Air Force to active duty servicemembers, should replace routine
physical exams. According to their Surgeon General representatives, the
Army and the Navy intend to change their regulations relating to periodic
physical exams and to adopt the recommendations offered by the AFEB by
2005. This shift in requirements is in line with recommendations of the
U.S. Preventive Services Task Force and many other medical
organizations,11 which no longer advocate routine physical exams for
adults-recommending instead a more selective approach to detecting and
preventing health problems.

                                 VA's C&P Exam

Some servicemembers who leave the military file for VA disability
benefits, which could include priority access to VA health care as well as
monthly payments for disabilities, diseases, or injuries incurred or
aggravated during active military service. VA requires evidence of
military service to confirm eligibility for these benefits, and the
department uses the C&P exam to establish a disability rating, which helps
determine the amount of compensation a veteran receives. Veterans retain
the option of initiating claims at any time after leaving the military,
even if they did not state their intention to do so on the medical
assessment form completed when they left military service.

A VA C&P exam is a physical exam used to determine a veteran's degree of
disability in support of claims for service-connected disability
compensation. The exam obtains information on the veteran's medical
history and includes diagnostic and clinical tests, the scope of which
depend on what disabilities the veteran claims. For example, if a veteran
claims a disability for a knee injury, VA would require a comprehensive
orthopedic exam to determine the percent of movement that has been lost
due to the knee injury. Veterans may claim multiple disabilities-all of
which must be evaluated for disability rating purposes.

In general, VA's C&P exam is more comprehensive and detailed than the
military services' separation exams, as military service exams are
intended to document continued fitness for duty, whereas the purpose of
the VA C&P exam is to document disability or loss of function regardless
of its

11The 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.

impact on fitness for duty.12 VA physicians who conduct the C&P exam must
evaluate the extent of a veteran's physical limitations and determine
their impact on the veteran's future employment for compensation purposes.
VA physicians usually conduct C&P exams at VA Medical Centers, although
since 1996 VA has had authority to use civilian physicians to provide C&P
exams at 10 VA regional offices.13 In addition, VA physicians may provide
C&P exams at some military medical facilities. According to VA officials,
the average cost of VA's C&P exam, exclusive of any diagnostic tests, is
about $400 when conducted by either VA or by VA's contractor.

Pilot Program for Single Separation Exams

In 1994, the Army and VA jointly initiated a pilot program for single
separation exams at three Army installations. Each of the installations
used a different approach when implementing the exam.

o  	At Fort Hood, Texas, a VA physician performed single separation exams
at the Army's military treatment facility.

o  	At Fort Knox, Kentucky, a sequential approach was used in which Army
personnel performed some preliminary work, such as lab tests and optical
exams, for servicemembers at the installation. Servicemembers were then
transported to a local VA medical center, where VA physicians completed
the single separation exams.

o  	At Fort Lewis, Washington, an Army physician performed the single
separation exams at the military installation.

The 1997 report on the pilot programs concluded that all of the approaches
for single separation exams were successful and that, overall, they
eliminated redundant physical exams and medical procedures, decreased
resource expenditures, increased the timeliness of VA's disability rating
decisions, and improved servicemembers' satisfaction. The report also
recommended that single separation exam programs be expanded to include
all military services.

12Determining that separating or retiring servicemembers are fit for duty
at separation ensures that they are not entitled to compensation from DOD
because of physical disabilities.

13See Veterans' Benefits Improvements Act of 1996, Pub. L. No. 104-275, S:
504, 110 Stat. 3322, 3341-3342. VA currently has a contract with QTC, a
private contractor, to conduct C&P physical exams at locations serviced by
the 10 regional offices in Atlanta, Georgia; Boston, Massachusetts;
Houston/San Antonio, Texas; Los Angeles, California; Muskogee, Alabama;
Roanoke, Virginia; Salt Lake City, Utah; San Diego, California;
Seattle/Spokane, Washington; and Winston-Salem, North Carolina.

VA and DOD Direction and Guidance for the Establishment of Single
Separation Exam Programs at Local Levels

Based on the findings of the single separation exam pilot, VA's Under
Secretary for Health and DOD's Acting Assistant Secretary of Defense for
Health Affairs signed an MOU in 1998 directing local VA offices and
military medical facilities to negotiate and implement individual MOUs for
single separation exam programs. According to the MOU, VA and the military
services should optimize available resources, including the use of both
military and VA facilities and staff as appropriate. For example, because
a servicemember applying for VA benefits would receive a single physical
exam that meets VA C&P exam requirements-which are usually more extensive
than the military services' separation exam requirements- the MOU
envisioned that VA medical personnel would perform most of the single
separation exams.14 It also stated that the military services would
provide VA with servicemembers' medical records and lab and test results
from active duty in order to avoid duplicative testing. Finally, the MOU
acknowledged that in implementing single separation exam programs,
negotiations between local VA and military officials would be necessary,
because military installations and local VA offices and hospitals face
resource limitations and competing mission priorities. These local level
negotiations would be documented in individual MOUs.

To implement the 1998 MOU, both VA and DOD issued departmentspecific
guidance. In January 1998, both VA's Under Secretary for Health and Under
Secretary for Benefits distributed guidelines to VA regional offices and
medical centers about completing the single separation exams in
cooperation with the military services. In September 1998, DOD's Assistant
Secretary of Defense for Health Affairs issued a policy to the Assistant
Secretaries for the Army, Navy, and Air Force stating that servicemembers
who leave the military and intend to file a claim for VA disability
benefits should undergo a single physical exam for the military services
and VA.

14However, in those geographic areas where VA may not reasonably be able
to provide examining physicians, the MOU stated that DOD physicians shall
perform the single separation exam using VA protocols.

  VA and the Military Services Have Established Some Single Separation Exam
  Programs, But Program Monitoring Is Lacking Despite Plans for Expansion

Since 1998, VA and the military services have collaborated to establish
single separation exam programs using various approaches to deliver the
exams, including those used in the original pilot program. However, while
we were able to verify that the exams were being delivered at some
installations, DOD, its military services, and VA either could not provide
information or provided us with inaccurate information on program sites.
Although VA reported that 28 of 139 BDD sites had programs in place as of
May 2004, we found that 4 of the 8 sites we evaluated from VA's list did
not actually have a program in place. Nonetheless, VA and DOD leadership
continue to encourage the establishment of single separation exam programs
and have drafted a new MOA that contains a specific implementation goal to
have programs in place at all of the BDD sites by December 31, 2004-an
ambitious goal given the seemingly low rate of program implementation
since 1998 and the lack of accurate information on existing programs.

Single Separation Exams Being Delivered at Some Locations Using Different
Approaches

VA reported that as of May 2004, 28 of the 139 BDD sites had operating
single separation exam programs. At these sites, VA officials told us,
local VA and military officials have implemented the program using one of
five approaches that met both the military services' and VA's requirements
without duplication of effort. Three of the five approaches were developed
during the 1994 pilot program-(1) military physicians providing the exams
at military treatment facilities, (2) VA physicians providing the exams at
military treatment facilities, and (3) a sequential approach wherein VA
and the military service shared the responsibility of conducting
consecutive components of a physical exam. In addition, VA officials
reported a fourth approach that was being used, in which VA physicians
delivered the single separation exam at VA hospitals, and a fifth
approach, in which VA used a civilian contractor to deliver the exams.

We evaluated the operation of the single separation exam programs at four
of the military installations VA reported as having collectively conducted
over 1,400 exams in 2003. These installations were conducting single
separation exams using two of the approaches-either with VA's contractor
conducting the physical exam or as a sequential approach. (See table 2.)
Overall, VA and military officials told us that both approaches worked in
places where military officials and VA officials collaborated well
together.

Table 2: Approaches Used to Deliver Single Separation Exams at Selected
Military Installations

                                                             Number of single
                                           Single separation separation exams
                Military installation Location exam approach reported in 2003

                                      ARMY

Fort Drum New York Sequential

Fort Eustis Virginia VA contractor

Fort Stewart Georgia VA contractor

                                      NAVY

Naval Station Mayport Florida Sequential

                                  Total 1,438

Source: GAO analysis of VA information.

At two Army installations-Fort Stewart and Fort Eustis-we found that VA
used its civilian contractor to conduct C&P exams, which the Army then
used to meet its separation exam requirements for servicemembers leaving
the military. At the Fort Drum Army installation and Naval Station
Mayport, local VA and military service officials collaborated to implement
a sequential approach. At Fort Drum, the Army starts the single separation
exam process by conducting hearing, vision, and other diagnostic testing.
A VA physician subsequently completes the actual physical exam at the
installation, which is then incorporated in the servicemember's medical
record. At Naval Station Mayport, a Navy corpsman starts the sequential
process by reviewing the servicemember's medical history, initiating
appropriate paperwork, and scheduling the servicemember for an appointment
with a VA physician. The VA physician then conducts a VA C&P exam at the
installation and completes the paperwork to meet the Navy's separation
requirements.

DOD, the Military Services, and VA Do Not Adequately Monitor Single
Separation Exam Programs

DOD and its military services do not adequately monitor where single
separation exam programs have been established. DOD does not maintain
servicewide information on the locations where single separation exam
programs are operating. While the Army and the Air Force each provided a
list of installations where officials claimed single separation exam
programs were established, both lists included installations that we
verified as not having a program in place. A Navy official told us that
although the Navy attempted to identify the locations of single separation
exam programs, its information was not accurate.

In addition, while VA maintains a list of single separation exam programs,
this list was not up to date. At our request, VA attempted to update their
list and reported to us that in May 2004, 28 military installations with
BDD programs also had single separation exam programs. At these sites, VA
reported that over 11,000 single separation exams had been conducted in
2003. However, when we evaluated programs at 8 of these installations, we
found that 4 of the installations did not actually have programs in place.
(See table 3.)

Table 3: Installations That VA Incorrectly Reported as Having Single
Separation Exam Programs

Number of single separation exams Military installation Location
reportedly delivered in 2003 ARMY

Fort Lee Virginia

                                   AIR FORCE

                    Little Rock Air Force Base Arkansas 237

Pope Air Force Base North Carolina

                                    MARINES

Camp Lejeune North Carolina 1,712

Total 2,075

Source: GAO analysis of VA information.

At these four military installations, the 2,075 exams reported as single
separation exams were actually VA C&P exams that were used only by VA and
not by the military services. We obtained the following information about
these installations.

o  	At Fort Lee, local Army and VA officials told us that a single
separation exam program was in place prior to our site visit. However,
during a joint discussion with us, they realized that the local MOU, which
was signed in April 2001, was not being followed and that the single
separation exam program was no longer in operation. Nonetheless, local VA
officials responsible for reporting on the program were unaware that the
program was no longer operational.

o  	At Little Rock Air Force Base, we found that a single separation exam
program was not in place even though there was an MOU, which local VA
officials told us was signed in May 1998. During our initial discussions,
local VA officials told us that the program was in operation. However, as
they responded to VA headquarter's inquiry to update their list of
installations with single separation exam programs for us, local officials

realized that the program was not in operation and had never existed
despite the signed MOU. Nonetheless, this site was still included on the
updated list of installations that VA provided to us.

o  	At Pope Air Force Base, local military officials told us that no
single separation exam program was in place. Furthermore, a local VA
official said that no MOU had been signed for the program at this
installation. However, despite this, local VA officials mistakenly
believed that installation officials were using the VA C&P exams to meet
their separation requirements and that, as a result, single separation
exams were being provided.

o  	Finally, at Marine Camp Lejeune, local military and VA officials told
us that no single separation exams were being conducted even though there
was an MOU, which was signed in 2001. When we met with the installation's
hospital commander, he told us that the hospital was not participating in
the single separation exam program, and he was unaware of the existence of
the MOU for this program. We also met with military officials at the
Hadnot Branch Clinic, the installation's busiest clinic in terms of
separation physicals, and at the time of our review, this clinic was also
not participating in the single separation exam program. Furthermore,
local VA officials told us that they realized that the program was not in
operation at the time of our visit-even though it was included on the list
that VA updated for us.

We also identified another military installation that had a single
separation exam program-even though it was not included in VA's list of
installations with these programs. Regional VA officials told us-and we
confirmed-that an MOU for a single separation exam program had been
implemented at MacDill Air Force Base, Florida. At this installation,
local military officials reported that 516 single separation exams were
conducted in 2003. According to local VA and military officials, this
installation employs a sequential approach wherein VA uses medical
information from Air Force health assessments as well as any diagnostic
tests that may have been conducted in conjunction with them to help
complete C&P exams for servicemembers applying for VA disability
compensation.

VA and DOD Leadership Continue to Encourage the Establishment of Single
Separation Exam Programs Through a New National Agreement

As part of an overarching effort to streamline servicemembers' transition
from active duty to veterans' status, VA and DOD continue to encourage the
establishment of single separation exam programs and have drafted a
national MOA, which is intended to supercede the 1998 MOU. Unlike the
original MOU, the draft MOA contains a specific implementation goal- that
VA and the military services establish single separation exam programs at
each of the installations with BDD programs by December 31, 2004. The
draft MOA also provides more detail about how the military services and VA
will share servicemembers' medical information to eliminate duplication of
effort. For example, the MOA states that the military services will share
the medical assessment forms along with any completed medical exam reports
and pertinent medical test results with VA. Similarly, the MOA specifies
that when VA conducts its C&P exam of servicemembers before they leave the
military, this information should be documented in servicemembers'
military medical records. According to VA officials, the draft MOA extends
the eligibility period for servicemembers to participate in the program by
eliminating the previous requirement that servicemembers had to have a
minimum number of days-usually 60-remaining on active duty. As a result,
servicemembers may participate in the program when they have 180 days or
less remaining on active duty.

Aside from some specific additions, the general guidance in the draft MOA
is consistent with the 1998 MOU. For example, the draft MOA delegates
responsibility for establishing single separation exam programs to local
VA and military installations, based on the medical resources-including
physicians, laboratory facilities, examination rooms, and support staff-
available to conduct the exams and perform any additional testing. The MOA
also continues to provide flexibility that allows local officials to
determine how the exams will be delivered-by VA, by VA's contractor, or by
DOD.

According to VA, the draft MOA is expected to be signed by DOD's Under
Secretary of Defense for Personnel and Readiness and the Deputy Secretary
of VA in November 2004. In contrast, the 1998 MOU was signed at lower
levels of leadership within each department-DOD's Acting Assistant
Secretary of Defense for Health Affairs, who reports to the Under
Secretary of Defense for Personnel and Readiness, and VA's Under Secretary
for Health, who reports to the Deputy Secretary of VA. Both VA and DOD
officials told us that endorsement for the new draft MOA from higher-level
leadership within the departments should facilitate the establishment of
single separation exam programs. However, it will be difficult to
determine where the program needs to be implemented

without accurate program information with which to oversee and monitor
these efforts-a critical deficiency in light of the MOA's ambitious goal
to establish the program at all BDD sites by December 31, 2004, and given
the seemingly low rate of implementation at the 139 BDD sites.

  Infrequent Use of Separation Exams Among Military Services and Other Factors
  Create Challenges in Establishing Single Separation Exam Programs

Several challenges impact the establishment of single separation exam
programs. The primary challenge is that the military services do not
usually require servicemembers to undergo a separation exam before leaving
the military. In fiscal year 2003, the military services administered
separation exams for an estimated one-eighth of servicemembers who left
the military. Consequently, although individual servicemembers may benefit
from single separation exams, the military services may not realize
benefits from resource savings through eliminating or sharing
responsibility for the separation exams. Another challenge to establishing
these programs is that some military officials told us that they need
their resources, such as space and medical personnel, for other
priorities, including ensuring the health of active duty servicemembers.
Furthermore, VA officials told us that because single separation exam
programs require coordination between personnel from both VA and the
military services, existing programs can be difficult to maintain because
of routine rotations of military staff to different installations.

The Military Services May Not Benefit from Single Separation Exam Programs
Due to Their Infrequent Use of Separation Exams

Despite increased convenience for individual servicemembers, the military
services may not benefit from single separation exam programs-designed to
eliminate the need for two separate exams-because the military services
usually do not require servicemembers who are leaving the military to have
separation exams. In fiscal year 2003, the military services administered
separation exams to an estimated 23,000, or one-eighth, of the
servicemembers who left the military that fiscal year. However, this
estimate may undercount the number of servicemembers who received
separation exams.15 (See fig. 1.)

15According to the DOD official who provided the data, some administered
separation exams may not be included in the estimate because they may have
been recorded as routine physical exams. However, according to this
official, this is the best information DOD has available on separation
physicals.

Figure 1: Estimated Percentage of Servicemembers Who Received Separation
Exams in Fiscal Year 2003

Percentage of separating service members who received a separation exam

Source: GAO analysis of DOD data.

Note: The data do not distinguish between mandatory separation exams and
separation exams that were requested by the servicemember. In addition,
according to the DOD official who provided the data, some separation exams
may not be included in the estimate because they may have been recorded as
routine physical exams.

Because the military services do not usually require separation exams, it
is unlikely that servicemembers will receive physical exams from both the
military and VA. At two Army installations without single separation exam
programs, we found that relatively few servicemembers had received both a
C&P exam from VA and a separation exam from the Army. From June 2002
through May 2004, 810 servicemembers received a VA C&P exam at Fort
Gordon, and of these, 121 soldiers-about 15 percent-had also received a
separation exam from the Army. Similarly, during June 2003 through May
2004, 874 servicemembers received a VA C&P exam at Fort Bragg, and of
these only 38-about 4 percent-had also received a separation exam from the
Army. Because the Army is the only military service to require separation
exams for all retirees, we expected that the Army's servicemembers were
more likely those of the other military services to receive two physical
exams. However, the small percentage of servicemembers that received both
VA C&P exams and Army separation exams at these two installations suggests
that the potential for resource savings by having single separation exams
is likely small.

In addition, some Air Force officials told us that they did not see a need
to participate in single separation exam programs because of their health
assessment requirements. For example, at Little Rock Air Force Base,
officials told us that because the Air Force does not routinely require
separation physicals for most servicemembers, it was not practical to use
VA's C&P physicals as single separation exams. The officials explained
that VA's C&P exams obtain more information than needed to meet the Air
Force's health assessment requirement and that using VA's exam as a single
separation exam would not be an efficient use of resources. The officials
said that it would take military medical personnel too much time to review
the VA C&P exams to identify the information the Air Force required.
Similarly, officials at other Air Force installations we visited- Hurlburt
Field, Langley Air Force Base, and Eglin Air Force Base-agreed that they
would not benefit from a single separation exam program. However, we did
find one Air Force installation-MacDill Air Force Base-where a single
separation exam program was operational, demonstrating the feasibility of
Air Force installations participating in single separation exam programs.

Some Military Officials Do Not Allocate Installation Resources for Single
Separation Exam Programs

Some military officials told us that they use their installations'
resources for other priorities than establishing single separation exam
programs. Although the 1998 MOU encouraged the establishment of these
programs for servicemembers leaving the military and filing VA disability
claims, some local military officials told us that their installations did
not currently have these programs because they decided to use available
resources to support other efforts, such as conducting wartime training
and ensuring that active duty servicemembers are healthy enough to perform
their duties. For example, when we visited Fort Bragg we learned that the
commander had initially agreed to provide space at his installation for a
single separation exam program. However, the same space was committed to
more than one function, and when the final allocation decision was made,
other mission needs took priority. In addition, Nebraska VA officials told
us that an existing single separation exam program was eliminated at
Offutt Air Force Base because military medical personnel assigned to help
VA physicians administer the exams were needed to focus on the health of
active duty servicemembers at the installation.

In addition, military officials explained that administering single
separation exams that include VA's C&P protocols are more time intensive
for their staff and can involve more testing than the military's
separation exams. As a result, military officials are reluctant to assign
resources,

including facilities and staff, to this effort. Further, military
officials explained that expending time and resources to train military
physicians to administer single separation exams is not worthwhile because
these physicians periodically rotate to other locations to fulfill their
active duty responsibilities so other military physicians would have to be
trained as replacements.

Military Staff Turnover Creates Challenges for Maintaining Established
Single Separation Exam Programs

Because single separation exam programs require coordination between
personnel from both VA and the military services, staff changes or
turnover can make it difficult to maintain existing programs. For example,
during our visit to the Army's Fort Lee, we found that the installation's
single separation program had stopped operating because of staff turnover.
When the program was in operation, a sequential approach was used in which
Army personnel conducted the initial part of the exams, which included
medical history and diagnostic testing, and then shared servicemembers'
medical records with VA personnel at the VA hospital, where the single
separation exams were completed. According to VA and Army officials, after
the Army personnel changed, the installation no longer provided VA with
the medical records.

Further, VA officials told us that maintaining joint VA and DOD
programs-such as single separation exam programs-is challenged by the fact
that military staff, including commanders, frequently rotate.16 According
to VA officials, some commanders do not want to continue agreements made
by their predecessors so single separation programs must be renegotiated
when the commands change. However, VA officials told us that the new draft
MOA should help alleviate this challenge to program establishment because
it states that local agreements between military medical facilities and VA
regional offices will continue to be honored when leadership on either
side changes.17

16Military commanders typically rotate about every 3 years.

17However, the draft MOA recognizes that changes to local agreements are
permissible as long as they address improved cooperation and changes in
resources and conform to the scope and responsibilities in the MOA.

  Conclusions

Recommendations for Executive Action

  Agency Comments

Since 1998, VA and DOD's military services have attempted to establish
single separation exam programs in order to prevent duplication and
streamline the process for servicemembers who are leaving the military and
intend to file a disability claim with VA. However, according to VA, fewer
than 30 out of 139 military installations with BDD programs had single
separation exam programs as of May 2004. To encourage more widespread
program establishment, the departments have drafted a new national MOA
with the goal of having programs in place at all BDD sites by December 31,
2004. Increasing the single separation exam program to all BDD sites will
allow more servicemembers to benefit from its convenience. Yet, given the
seemingly low rate of program implementation since 1998 and the challenges
we identified in establishing and maintaining the program, it is unlikely
that the programs will be established at about 100 more sites less than 2
months after the MOA becomes effective. Consequently, both departments
will need to monitor program implementation to ensure that the new MOA is
put into practice- especially since local agreements for single separation
exam programs have not always resulted in the establishment and operation
of such programs.

To determine where single separation exam programs are established and
operating, we recommend that the Secretary of VA and the Secretary of
Defense develop systems to monitor and track the progress of VA regional
offices and military installations in implementing these programs at BDD
sites.

We requested comments on a draft of this report from VA and DOD. Both
agencies provided written comments that are reprinted in appendices IV and
V. VA and DOD concurred with the report's findings and recommendation. DOD
also provided technical comments that we incorporated where appropriate.

In commenting on this draft, VA stated that it has actions underway or
planned that meet the intent of our recommendation. First, it has
established an inspection process of BDD sites to determine compliance
with procedures. In addition, VA noted that it has worked with DOD to
revise the MOA for single separation exam programs and that it has
instructed its regional offices to begin working with military treatment
facilities to implement its provisions. Finally, VA said that VA's and
DOD's joint strategic plan for fiscal year 2005 will include substantive

performance measures to monitor the process of moving from active duty to
veteran status through a streamlined benefits delivery process.

In their written comments, DOD recognized the importance of a shared DOD
and VA separation process and its benefits to servicemembers and noted the
fact that both departments are working on an MOA to further encourage
single separation exams. DOD also stated that the capability to monitor
and track the progress of single separation exams has been hampered by the
lack of a shared VA and DOD information technology system. However, DOD
reported that VA is developing automated reporting tools and will be doing
on-site visits to BDD sites, and VA and DOD will share information
gathered from this system and site visits.

We are sending copies of this report to the Secretary of Defense, the
Secretary of Veterans Affairs, appropriate congressional committees, and
other interested parties. We will also make copies available to others
upon request. In addition, the report is available at no charge on the GAO
Web site at http://www.gao.gov. If you or your staff have questions about
this report, please contact me at (202) 512-7119. Other contacts and staff
acknowledgments are listed in appendix VI.

Marcia Crosse Director, Health Care-Public Health and Military Health Care
Issues

                       Appendix I: Scope and Methodology

To identify efforts by the Department of Veterans Affairs (VA) and the
military services to establish single separation exam programs for
servicemembers who plan to file VA disability claims, we reviewed
pertinent legislation and obtained VA's requirements for compensation and
pension (C&P) exams. We also obtained service-specific requirements for
periodic physical exams and health assessments and evaluations, especially
those requirements pertaining to separating and retiring servicemembers.1
We obtained and reviewed relevant documentation about both departments'
efforts to establish single separation exam programs. We also interviewed
officials from the office of the Assistant Secretary of Defense for Health
Affairs, the military services' Surgeons General, and VA. In addition, we
obtained VA's data on the number of disability claims and the cost data
associated with conducting military physical exams and VA C&P exams. Based
on our review of these data and subsequent discussions with agency
officials, we determined that these data were sufficiently reliable for
the purposes of this report.

We obtained a list of 28 military installations that VA officials had
identified as having single separation exam programs through a survey of
their Benefits Delivery at Discharge (BDD) sites. We used this list to
select 8 installations to learn how their programs operated. We did not
verify whether the remaining 20 installations had single separation exam
programs because such verification would have required a full evaluation
of actual program operations at these locations. We also did not verify
the number of installations with BDD sites or the numbers of single
separation exams VA reported for these military installations. We selected
installations that represented each of VA's reported approaches for
operating the single exam program-VA physicians conducting the exam at
military installations, VA physicians conducting the exam at VA medical
centers, Department of Defense (DOD) physicians conducting the exam, VA
and DOD using a sequential approach for the exam, and VA's civilian
contractors delivering the exam. The installations we selected represented
each of the four branches of the military service-Army, Navy, Air Force,
and Marines-and all but one had more than 500 servicemembers leave in
fiscal year 2003.2 We obtained the separation data from the Defense

1This report excluded reservists and was limited to include those active
duty servicemembers separating due to retirement or completion of their
tour of active duty.

2Little Rock Air Force Base had less than 500 separations in fiscal year
2003, but was selected because it represented the model where VA
physicians conducted single separation exams at VA medical facilities.

Appendix I: Scope and Methodology

Manpower Data Centers' (DMDC) Active Duty Military Personnel file on the
number of servicemembers who left the military from various separation
locations during fiscal year 2003. To assess the reliability of these
data, we conducted logic tests to identify inconsistencies, reviewed
existing information about it and the system that produced it, and
interviewed an agency official who was knowledgeable about the data. We
determined the data to be sufficiently reliable for the purposes of this
report.

From VA's list we visited seven military installations-Marine Corps Base
Camp Lejeune, North Carolina; Fort Eustis, Virginia; Fort Lee, Virginia;
Fort Stewart, Georgia; Little Rock Air Force Base, Arkansas; Naval Station
Mayport, Florida; and Pope Air Force Base, North Carolina. We also
conducted telephone interviews with medical command and VA officials
associated with Ft. Drum, New York. Further, we conducted a telephone
interview with military and VA officials from MacDill Air Force Base,
Florida, which has a single separation exam program but was not on VA's
list. At the installations we visited or contacted, we spoke with medical
command officials and with VA officials responsible for the single
separation exam program to discuss the different types of local agreements
and procedures used for delivering single separation exams.

We also reviewed the draft memorandum of agreement (MOA) related to single
separation exam programs and interviewed officials from VA, the Office of
the Assistant Secretary of Defense for Health Affairs, and the services'
Surgeons General to obtain information on VA and DOD officials' efforts to
draft and implement this MOA.

To obtain information on the challenges associated with establishing
single separation exam programs, we identified and visited military
installations that did not have single separation exam programs. We used
DMDC's separation data for fiscal year 2003 to identify installations
representing each of the military services-Army, Navy, Air Force, and
Marines-that had more than 500 separations and were not reported by VA as
having a single separation exam program. We also visited installations
that were located in the same VA regions as installations we visited that
VA had reported as having single separation exam programs. The seven
military installations we visited were Marine Corps Air Station Cherry
Point, North Carolina; Eglin Air Force Base, Florida; Fort Bragg, North
Carolina; Fort Gordon, Georgia; Hurlbert Field Air Base, Florida; Langley
Air Force Base, Virginia; and Naval Station Norfolk, Virginia. At these
installations, we interviewed medical command officials and VA officials
to learn whether single separation exam programs had been considered

Appendix I: Scope and Methodology

and what the challenges were to establishing them. For the two Army
installations included in these seven selected installations-Fort Bragg,
North Carolina and Fort Gordon, Georgia-we obtained both the separation
exam data and C&P exam data for each installation to determine how many
separating servicemembers from each installation received both an Army
separation exam and a VA C&P exam. We chose Army installations for this
analysis because duplicate service and C&P exams were more likely to occur
due to the Army's requirement that retirees receive a physical exam. After
our review of the documentation and subsequent discussions with agency
officials, we concluded that these data were sufficiently reliable for the
purposes of this report. We also reviewed DOD's separation exam data and
discussed it with an agency official. Based on this information, we
concluded that these data were sufficiently reliable for the purposes of
this report although it may understate the number of separation exams
because some may have been identified more generally as physical exams.

To obtain additional information on the challenges to establishing single
separation exam programs, we called or visited VA regional offices in 16
locations-Arkansas, California (three regions), Georgia, Florida,
Kentucky, Nebraska, New York, North Carolina, Oklahoma, South Carolina,
Texas (two regions), Virginia, and Washington-and talked with officials
responsible for initiating and implementing these programs. We selected
six of these regional offices because they were already involved in
establishing single separation exam programs at the eight military
installations we selected from VA's list. We asked these officials about
the challenges they encountered when trying to establish these programs at
other installations in their regions. We also interviewed officials from
the three VA regional offices involved in the pilot program for single
separation exams. We talked with officials from seven additional regional
offices that had responsibility for military installations with more than
500 separations during fiscal year 2003 to determine how they established
programs in their regions and problems they encountered when programs
could not be established.

We performed our work from January 2004 through November 2004 in
accordance with generally accepted government auditing standards.

Appendix II: DOD's Form 2697 - Report of Medical Assessment

Appendix II: DOD's Form 2697 - Report of Medical Assessment

Appendix III: DOD's Form 2808 - Report of Medical Examination

Appendix III: DOD's Form 2808 - Report of Medical Examination

Appendix III: DOD's Form 2808 - Report of Medical Examination

Appendix IV: Comments from the Department of Veterans Affairs and GAO's Response

Appendix IV: Comments from the Department of Veterans Affairs and GAO's
Response

Appendix IV: Comments from the Department of Veterans Affairs and GAO's
Response

                              Now on pp. 3 and 4.

See comment 1.

Now on page 4.

See comment 2.

Appendix IV: Comments from the Department of Veterans Affairs and GAO's
Response

                         Now on page 8. See comment 3.

                                Now on page 14.

                                 See comment 4.

                                Now on page 14.

Appendix IV: Comments from the Department of Veterans Affairs and GAO's
Response

                                 See comment 5.

                                Now on page 18.

Appendix IV: Comments from the Department of Veterans Affairs and GAO's
Response

  GAO Comments

The following are GAO's comments on the VA November 1, 2004, letter.

1. We used VA's May 2004 updated list to select our sites, and we found
that it contained information that was both incomplete and inaccurate. The
list included installations where we did not find single separation exam
programs. It also omitted one installation where we found a single
separation exam program.

2. We agree that individual servicemembers will benefit from single
separation exam programs and have added information to the body of the
report to reflect this.

3. We modified this statement as follows: "In general, VA's C&P exam is
more comprehensive and detailed than the military services' separation
exams, as military service exams are intended to document continued
fitness for duty, whereas the purpose of the VA C&P exam is to document
disability or loss of function regardless of its impact on fitness for
duty."

4. Although VA believed the C&P exam was being used for separation
purposes at Pope Air Force Base, it was not. As we reported, VA and DOD
had not signed an MOU for a single separation exam program at this
installation, and the Air Force was clear that it was not using the C&P
exam for separation purposes.

5. While Camp Lejeune's Hadnot Branch Clinic may currently be conducting
single separation exams, at the time of our visit in June 2004, the
physician at the Hadnot Clinic told us he was not using VA's C&P exams for
servicemembers' separation exams. In September 2004, we confirmed this
information with the clinic physician.

                 Page 36 GAO-05-64 Single Physical Exam Process

                 Page 37 GAO-05-64 Single Physical Exam Process

Appendix VI: GAO Contacts and Staff Acknowledgments

  GAO Contacts Acknowledgments

(290392)

Bonnie Anderson, 404-679-1900 Lois Shoemaker, 404-679-1900

In addition to those named above, key contributors to this report were
Krister Friday, Cywandra King, Raj Premakumar, Allan Richardson, and
Julianna Williams.

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