Defense Health Care: Problems with Medical Care Overseas Are Being
Addressed (Letter Report, 07/12/95, GAO/HEHS-95-156).

Pursuant to a congressional request, GAO reviewed beneficiary access to
military health care in Europe, focusing on the: (1) availability of
health care in military facilities; (2) obstacles in providing military
health care; (3) experiences of beneficiaries that have used host nation
providers instead of military health care providers; and (4) Department
of Defense's (DOD) handling of service delivery problems and beneficiary
concerns.

GAO found that: (1) since the downsizing of U.S. military personnel in
Europe, beneficiaries have found it difficult to obtain health services
at overseas military facilities; (2) although beneficiaries have access
to primary health care services, their access to specialty and dental
care services is limited; (3) the reduced military health care system
has resulted in DOD relying on the German and Italian medical systems to
provide health services to beneficiaries; and (4) beneficiaries must
contend with language barriers, cultural differences, unfamiliar
doctors, and the general lack of information about how to obtain host
nation health care; In addition, GAO found that DOD: (1) is developing
an interservice health care plan for all beneficiaries in Europe; (2)
has hired liason personnel to help beneficiaries obtain health care from
German and Italian health care providers; and (3) plans to contract for
services to monitor the care that beneficiaries receive from host nation
providers, an education program that explains beneficiary health care
options in Europe, and the translation of host nation medical records.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-95-156
     TITLE:  Defense Health Care: Problems with Medical Care Overseas 
             Are Being Addressed
      DATE:  07/12/95
   SUBJECT:  Beneficiaries
             Military downsizing
             Military hospitals
             Military dependents
             Armed forces abroad
             Health care services
             Dental services
             Military forces
             Military cost control
IDENTIFIER:  Civilian Health and Medical Program of the Uniformed 
             Services
             Europe
             Germany
             Italy
             CHAMPUS
             
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Cover
================================================================ COVER


Report to the Honorable Ike Skelton
House of Representatives

July 1995

DEFENSE HEALTH CARE - PROBLEMS
WITH MEDICAL CARE OVERSEAS ARE
BEING ADDRESSED

GAO/HEHS-95-156

Medical Care Overseas


Abbreviations
=============================================================== ABBREV

  CHAMPUS - Civilian Health and Medical Program of the Uniformed
     Services
  DOD - Department of Defense
  MHSS - military health services system

Letter
=============================================================== LETTER


B-259399

July 12, 1995

The Honorable Ike Skelton
House of Representatives

Dear Mr.  Skelton: 

The American military presence in Europe has declined dramatically
since 1989.  The active duty population has been reduced by 57
percent--from about 322,000 to 138,000.  At the same time, the
military health services system (MHSS) has also been substantially
cut back.  During this period of downsizing, many beneficiaries have
expressed concern about their reduced access to health care from
military medical facilities overseas and dissatisfaction with care
they received from host nation providers.  They have charged that the
Department of Defense (DOD) is not doing enough to ensure access to
appropriate health care during the drawdown. 

Citing these concerns, you asked that we review beneficiary access to
military health care in Europe.  Specifically, you asked that we
provide information on (1) the availability of health care in
military facilities, (2) any obstacles to providing that care, (3)
the experiences of beneficiaries that have used host nation providers
as an alternative to military health care, and (4) whether DOD is
addressing service delivery problems and beneficiary concerns. 

To develop this information, we visited 15 military communities in
Germany and northern Italy.  Many of the beneficiary complaints about
medical and dental care that were made to DOD and Members of Congress
originated in these communities.  While there, we conducted numerous
interviews with military health care providers, officials in host
nation facilities, and beneficiaries. 

We also held discussions with and reviewed available documents
provided by the military medical leadership in Europe, officials in
the Offices of the Surgeons General, and top officials in the Office
of the Assistant Secretary of Defense (Health Affairs).  Appendix I
contains a more detailed discussion of our scope and methodology. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Since the downsizing began in 1989, beneficiaries have generally
found it more difficult to obtain health services at military
facilities.  Beneficiaries have access to primary care, but for some,
particularly non-active duty beneficiaries, access to specialty care
varies and is often inconvenient.  Military medical personnel must
overcome many obstacles to provide the care that is offered.  These
personnel are hampered by staff shortages, long waits for laboratory
test results, and equipment failures. 

The reduced military health care system has resulted in DOD's placing
a greater reliance on the German and Italian medical systems for
providing treatment to beneficiaries.  Beneficiaries, however, must
contend with language barriers, cultural differences, unfamiliar
doctors, quality of care concerns including differences in treatment,
and a general lack of information about how to obtain host nation
care.  Additionally, active duty family members using host nation
providers were, until October 1, 1994, required to pay deductibles
and copayments for their care. 

To address these problems and concerns, DOD has taken or is planning
to take a number of actions.  For example, DOD is developing an
interservice health care plan for all beneficiaries in Europe that
seeks to maximize the use of military medical facilities supplemented
by a network of German and Italian health care providers.  DOD has
also hired liaison personnel to help beneficiaries obtain health care
from German and Italian providers.  DOD now pays the deductibles and
copayments of families of active duty members who obtain after-hours
emergency services or routine care at host nation facilities.  DOD
also plans to contract for (1) services to monitor the care that
beneficiaries receive from host nation providers, (2) an education
program that explains beneficiary health care options in Europe, and
(3) the translation of host nation medical records.  Although each of
these actions is positive, some have been slow to materialize.  DOD's
goal is to have all of these measures in place by October 1995. 


   BACKGROUND
------------------------------------------------------------ Letter :2

The MHSS consists of military medical facilities and private sector
health care providers.  The primary mission of the MHSS is to
maintain the health of military personnel and to support the services
during time of war.  In addition, the MHSS provides health care to
dependents of active duty members, retirees and their dependents, and
survivors of service members.  Active duty members receive their care
almost entirely from military medical facilities.  When space and
resources are available, other beneficiaries may obtain their care
from military medical facilities as well.  Overseas, U.S.  civilian
government employees are also eligible to receive care in military
medical facilities on a space-available basis. 

The collapse of the Warsaw Pact and the end of the Cold War have
significantly changed the American military landscape in Europe. 
Because of the easing of East-West tensions, the United States has
chosen to substantially reduce its military forces in Europe. 
Between July 1990 and April 1993, DOD initiated three major plans to
reduce its military forces in Europe, each with successively lower
personnel levels.  The first plan, developed in July 1990, would have
reduced military positions in Europe to 225,000; the second to
150,000; and the latest plan calls for about 100,000 Army, Air Force,
and Navy personnel in Europe by the end of fiscal year 1996. 

The U.S.  military medical system in Europe has also been reduced and
reorganized.  The number of military hospitals and clinics in Europe
is being cut from 23 hospitals and 89 clinics in 1989 to 9 hospitals
and 48 clinics in 1995.  In Germany, for example, the Air Force is
reducing its hospitals from three to one and its clinics from six to
five.  Army hospitals and clinics in Germany are being reduced from 9
to 3 and 55 to 25, respectively.  In northern Italy, the Air Force
has one clinic and the Army has one hospital and one clinic, the same
as in 1989.  The Army, however, plans to convert the hospital to a
clinic in October 1995 because (1) very low utilization makes it
difficult to maintain a high-quality hospital and (2) quality medical
care is available from host nation providers.  Appendix II lists
those Air Force and Army medical facilities operating as of April 21,
1995. 

The number of dental clinics is also being significantly cut back. 
Prior to the downsizing, the Army had 94 dental clinics in Europe. 
The Army has completed its reduction and now has 35 dental clinics. 
The Air Force is reducing its dental clinics from 31 to 11. 


   BENEFICIARIES HAVE ACCESS TO
   PRIMARY CARE BUT SPECIALTY AND
   DENTAL CARE ARE LIMITED
------------------------------------------------------------ Letter :3

Beneficiaries have access to primary care at military facilities,
including outlying clinics.  Most of the outlying clinics are closed
in the evenings and on weekends, however, necessitating that
after-hours primary care and emergency services be obtained from
German and Italian providers.  In general, U.S.  military specialty
care is available to active duty personnel and is most accessible to
beneficiaries living near U.S.  military hospitals.  Dental care is
more readily available to active duty personnel than other
beneficiaries. 


      MOST BENEFICIARIES CAN
      OBTAIN PRIMARY CARE AT
      MILITARY FACILITIES
---------------------------------------------------------- Letter :3.1

Military providers told us that primary care clinics are able to
serve most beneficiaries.  Since 1989, the ratio of primary care
providers (general medical officers, family practice physicians,
physician's assistants, and nurse clinicians) to beneficiaries has
improved--from 1:1,222 to 1:868--and plans call for further
improvement to 1:661 by November 1995.  Generally, clinics are open
Monday through Friday, and some have extended hours--one evening
during the week or morning hours on the weekend.  Two Army clinics in
Germany are open 24 hours, 7 days a week.  Beneficiaries in all
categories expressed general satisfaction with their access to
primary care in military facilities.  They did, however, express
frustration over difficulties in making appointments by telephone and
delays in obtaining routine physical exams and well-woman exams. 
They also stated concerns about delays in obtaining test results. 

Although the overall ratio of primary care providers is improving,
staff at many of the outlying clinics we visited mentioned that they
need more physicians trained in family practice and pediatrics.  Some
of the clinics had no family practice, pediatric, or other primary
care specialty physician except the clinic commander who also had
administrative and supervisory responsibilities.  Army clinics rely
heavily on general medical officers to provide primary care.  Army
officials stated that they do not have enough family practice or
other specialty-trained primary care physicians to assign to clinics. 


      ACCESS TO SPECIALTY CARE IN
      MILITARY FACILITIES VARIES
      AND CAN BE INCONVENIENT
---------------------------------------------------------- Letter :3.2

DOD was unable to provide us with data to compute how the ratios of
specialists to beneficiaries have changed since 1989 or to measure
how long it takes to get an appointment with a specialist.  However,
the military medical leadership, military physicians, and
beneficiaries all commented that there has been a significant
reduction in the amount and location of U.S.  military specialty care
available in Europe since the downsizing began.  As a result, access
to specialty care varies by specialty and among categories of
beneficiaries. 

Some specialty areas have substantially fewer physicians than before
the downsizing began.  For example, the number of Army
obstetricians/gynecologists has been reduced from 42 to 17;
urologists from 6 to 2; otolaryngologists (ear, nose, and throat)
from 8 to 4; general surgeons from 32 to 11; and orthopedic surgeons
from 26 to 11.  Only one specialty (nephrology), however, is no
longer available in Europe. 

Active duty members are generally able to obtain the specialty care
they need, although in some instances they must wait a month or
longer.  Service members needing inpatient psychiatric services are
sometimes sent back to the United States for such care because of
limited inpatient mental health resources in Europe.  Non-active duty
beneficiaries have less, and in some cases no, access to specialty
care, particularly otolaryngology, orthopedics, and mental
health--also because of limited resources.  Beneficiaries and
military medical officials commented that many people who need these
services must either wait a substantial period of time to get the
care from military facilities in Europe or return to the United
States for it. 

Access to specialty care is also less convenient because of the
reduction in U.S.  military hospitals.  In 1989 the Army had nine
hospitals in Germany.  Now U.S.  military specialty care is provided
almost entirely in the three remaining Army hospitals in Germany: 
Landstuhl, Wuerzburg, and Heidelberg.  Beneficiaries in Augsburg, for
example, must travel about 130 miles one way to obtain the specialty
care that is available at the U.S.  Army hospital in Wuerzburg or
about 170 miles one way to Landstuhl to obtain specialty care that is
not available in Wuerzburg.  Beneficiaries in many communities
throughout Germany find themselves in similar circumstances. 

Obtaining specialty care is also inconvenient for beneficiaries when
repeat hospital visits are required.  For example, most outlying
clinics do not have physical therapists or mental health
professionals on staff.  Consequently, patients must travel to one of
the military hospitals to obtain these recurring services.  Each
visit frequently requires patients to spend a full day traveling and
receiving services. 

To help beneficiaries living in remote areas, specialists assigned to
the three Army hospitals periodically visit clinics to provide care,
but these visits are infrequent.  Also, military communities provide
shuttle bus service to the nearest U.S.  military hospital.  In most
communities, the shuttle bus makes one trip daily between the
military community and the hospital, leaving early in the morning and
returning in the late afternoon of the same day.  In some
communities, however, the service is limited to only a few days each
week.  Regardless, making long trips for follow-up appointments
created hardships on family members and active duty service members
with family and work responsibilities.  Also, we were told that
soldiers' full-day absences from their assigned duties can adversely
affect their units' wartime readiness. 

In northern Italy, the Army plans to convert its hospital in Vicenza
to an outpatient clinic in October 1995.  The clinic will maintain an
after-hours acute care capacity to treat minor injuries and
illnesses.  Emergency and specialty care, now available at the
Vicenza Army hospital, will be provided by the city hospital in
Vicenza, by other Italian facilities, or by military facilities in
Germany or the United States.  (For some time now, life-threatening
emergencies have been sent to Vicenza's city hospital.) For other
military communities in northern Italy, such as Aviano and Livorno,
specialty care will continue to be provided by host nation
facilities, as it has since 1989. 

Relatively few military retirees and their dependents age 65 and
older live overseas.  Those that do are especially concerned about
their access to specialty health care because Medicare coverage does
not extend to beneficiaries living overseas.  DOD estimates that
fewer than 1,400 such beneficiaries reside in Europe.  These
beneficiaries, who have chosen to reside overseas, have been largely
dependent on the military health care system to provide their medical
care and, as a result, many have never purchased supplemental health
insurance through U.S.  or host nation health companies.  Obtaining
private insurance may not be an option for some elderly retirees and
family members because it is costly. 


      DENTAL CARE IS LIMITED
---------------------------------------------------------- Letter :3.3

Access to dental care is limited for many beneficiaries living in
Europe.  Active duty personnel have better access to dental care than
do their family members, who are generally able to obtain only
emergency dental care, annual examinations, and cleanings.  Many
beneficiaries, except for active duty, have limited or no access to
specialty dental care.  The dental staff in some clinics dedicate
most of their orthodontic care to patients whose treatment programs
were initiated in the United States.  New cases are seldom started. 
In Vicenza and Livorno, all beneficiaries have access to dental
services. 

Many beneficiaries and U.S.  military dentists do not consider host
nation dental care a viable option.  It is expensive, and
beneficiaries do not like the differences in the practice patterns of
host nation dentists. 


   THE MHSS IN EUROPE FACES
   NUMEROUS OBSTACLES
------------------------------------------------------------ Letter :4

Numerous obstacles confront the MHSS in Europe.  Some existed prior
to the downsizing, including medical staffing shortages, long waits
for laboratory results, and equipment problems.  Many U.S.  military
physicians stated that these obstacles hinder their ability to
provide quality medical care. 


      MHSS FACES PERSONNEL
      SHORTAGES AND OTHER STAFFING
      PROBLEMS
---------------------------------------------------------- Letter :4.1

Many clinic and hospital officials we met with stated that they have
too few military and civilian personnel.  Their facilities are
staffed at less than 100 percent of authorized military levels in
such positions as nurses, medics, X-ray technicians, and pharmacy
technicians.  In addition, medical staff frequently complained about
shortages in civilian personnel, including receptionists, custodians,
and patient liaisons.  Medical staff are working long hours
attempting to meet the demand for care. 

Two other factors have had a serious impact on the military's ability
to meet the health care needs of all beneficiaries in Europe.  First,
medical and dental units have been under additional strain to meet
the demand for care during the downsizing.  The military had intended
to keep medical resources in Europe at levels proportionally higher
than nonmedical units so that access to health care would be improved
during the downsizing.  To the contrary, many of the health and
dental clinics we visited were staffed at their so called "endstate"
levels, while nonmedical units had not yet reached their final
levels.  Army officials were unable to provide documents showing how
a coordinated withdrawal of medical and nonmedical personnel was
planned to ensure improved access to health care.  However, they did
provide data indicating that the ratios of total medical personnel to
beneficiaries have changed little since 1989--from 1:31 to 1:38. 
Over time, as more units withdraw from Europe, this tension should
ease somewhat. 

Second, until recently, Army medical units have not received
replacements when their medical personnel are temporarily reassigned
to other units.  Between October 1993 and December 1994 the Army in
Europe sent 715 men and women from medical units to other areas of
the world without providing replacement personnel for the affected
medical units.  These actions often resulted in immediate personnel
shortages for the medical units in Europe and further hindered the
delivery of health care to beneficiaries there.  The Army has
implemented a policy which calls for replacing medical personnel (not
necessarily on a one-for-one basis) who are temporarily assigned to
other units for more than 14 days.  Since March 1995, the Army has
provided temporary replacements to medical units in Europe. 


      EQUIPMENT PROBLEMS AND
      UNTIMELY LABORATORY TEST
      RESULTS
---------------------------------------------------------- Letter :4.2

Medical staff experience daily problems with equipment failures and
delays in obtaining laboratory test results.  Generally, these
problems are attributed to old and unreliable equipment.  Staff
repeatedly told us that X-ray, X-ray processor, and culture machines
are frequently broken.  They also mentioned that problems exist with
the ambulance fleet, defibrillators, CT scanners, and pulse oximeters
because they are old, outdated, or in short supply. 

Medical staff also experience problems in obtaining laboratory test
results.  Although data were unavailable on the specific or average
times needed to get laboratory results, staff said that all test
results require more time than they should to get back.  Results of
glucose, potassium, cholesterol, liver and thyroid function, and
tissue exams are typically delayed, as are X rays.  Health care
providers at one clinic estimated that it took between 2 and 4 weeks
to obtain the results for such tests.  They cited delays as long as 2
months for Pap test results.  DOD is currently implementing a medical
information system that will allow providers to obtain test results
via computer rather than mail.  The new computer system, officials
believe, should enable military providers to get laboratory results
in a more timely manner. 


   BENEFICIARIES ARE FRUSTRATED
   WHEN OBTAINING HOST NATION CARE
------------------------------------------------------------ Letter :5

Beneficiaries under age 65 who either are unable or do not want to
receive care from military medical facilities have the option of
obtaining care from host nation providers.\1

Although the beneficiaries we spoke with were generally satisfied
with the outcome of the host nation health care they received, they
expressed a great deal of frustration over their specific experiences
in obtaining that care.  They also expressed a strong preference to
receive their health care from military facilities.  Beneficiaries
and military medical officials agree, however, that as less and less
care is available from military medical facilities in Europe,
beneficiaries will have to rely more on host nation providers. 

Beneficiaries are frustrated with host nation medical care for a
variety of reasons.  Some host nation providers, for example, require
payment or a large deposit in advance of treating U.S.  military
beneficiaries.  These upfront payments, we were told, amount to as
much as the equivalent of about $6,000.  Also, U.S.  military
officials provide beneficiaries little information or help in
choosing German or Italian providers.  Essentially, beneficiaries are
given a list of English-speaking doctors and encouraged to ask other
beneficiaries about their experiences with these doctors before
selecting one.  In addition, beneficiaries feel abandoned by military
medical physicians when they use host nation providers.  In general,
military physicians are not required to actively monitor U.S. 
patients' care in host nation facilities.  Although they may be aware
of their patients' progress, the lack of direct contact gives
beneficiaries the impression that they have been "dumped" on host
nation providers and that the military is not concerned about their
care.  The Aviano community is an exception.  Several patient
assistance services have been in place for some time there.  For
example, the Air Force contracts with bilingual Italian physicians to
help beneficiaries understand their diagnosis and treatment. 

Beneficiaries also mentioned that they need help obtaining services
from host nation facilities, especially during evenings and weekends. 
They are concerned about such matters as knowing where to go, having
someone available to translate their medical emergency, and getting
assistance with paperwork.  In addition, beneficiaries using host
nation providers were required to pay deductibles and copayments for
their care.  When admitted, beneficiaries explained that they must
contend with language barriers, cultural differences, and quality of
care concerns such as differences in treatment.  Military physicians
told us that some differences in treatment do exist among the U.S.,
German, and Italian systems.  Although the cultural and treatment
differences are unsettling to U.S.  patients, the military medical
staff, for the most part, are confident about the quality of health
care delivered in Germany and northern Italy. 

Once care is completed and patients are released from host nation
providers, many patients are left with their medical information in a
foreign language.  This problem is most prevalent in Germany where,
currently, treatment records are written in German, and often the
only information translated is that done by bilingual physicians
working for the U.S.  military.  In several communities, military
physicians estimated that less than 10 percent of medical records are
ever translated.  Consequently, patients may not have an adequate
record of their medical conditions and treatments. 


--------------------
\1 The Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS), allows non-active duty beneficiaries to obtain health care
from private sector medical care providers.  The most current data
available indicate that, in fiscal year 1993, CHAMPUS costs in
Germany and Italy were about $30 million. 


   DOD ACTIONS TO ADDRESS
   BENEFICIARIES' CONCERNS
------------------------------------------------------------ Letter :6

DOD and beneficiaries recognize that there must be a greater reliance
on host nation care:  Rebuilding U.S.  military medical facilities
overseas is not an option.  Therefore, DOD has taken and is planning
a number of steps to alleviate beneficiary concerns and improve
access to host nation care.  Although some of DOD's actions have been
slow in coming, most are expected to be in place by October 1995.  In
our view, these actions are positive steps toward alleviating the
concerns voiced by beneficiaries.  However, the extent to which
beneficiaries will be satisfied remains to be seen. 

To address beneficiaries' overall concern, DOD is developing an
interservice health care plan for all beneficiaries in Europe that
seeks to maximize the use of military medical facilities.  This
effort is being headed by a tri-service executive steering committee
made up of senior medical officials in Europe and assisted by a
military treatment facility commander's council--a group representing
military hospital and clinic commanders in Europe.  Instead of
focusing on tangible outcomes, most efforts to date have focused on
planning, coordinating, and determining how the military services can
effectively work together to better serve their beneficiaries.  These
formative sessions represent a significant step because, in the past,
the services have essentially operated independently rather than
working in a collaborative way. 

Beginning in the summer of 1994, DOD also initiated efforts to
establish a preferred provider network in Europe, Africa, and the
Middle East.  Once completed, this network will enable beneficiaries
to choose among various host nation providers who (1) are interested
in serving them, (2) are willing to accept payment under CHAMPUS, and
(3) will not require advance payments from beneficiaries.  At the
outset approximately 20,000 host nation providers were identified as
having billed CHAMPUS for services.  DOD contacted these providers
and asked if they were willing to treat U.S.  beneficiaries,
outlining the conditions.  DOD is also working to ensure the quality
of network participants by verifying their qualifications.  As of
February 1995, over 4,000 of these providers had indicated an
interest in joining a CHAMPUS-preferred provider network.  In April
1995, the Army established a toll-free telephone number for
beneficiaries to obtain after-hours referrals to host nation
facilities.  The service is currently available at Army hospitals in
Heidelberg and Wuerzburg and is planned for Landstuhl as well. 

To assist beneficiaries who are using host nation providers, DOD
established a patient liaison coordinator program.  As of June 5,
1995, 59 patient liaisons were assigned to Europe.  These liaisons
(1) coordinate consultations with host nation facilities and
follow-up care, (2) help make appointments at host nation facilities,
(3) educate beneficiaries on host nation medical services, (4)
interpret information between host nation providers and
beneficiaries, (5) assist with paperwork associated with
hospitalization at host nation facilities, and (6) visit patients in
hospitals. 

Beneficiaries generally agree that the patient liaisons reduce the
anxiety involved in using host nation facilities.  However, most
communities have only one or two patient liaisons and whose services
are generally available only on weekdays until 4 p.m.  The patient
liaison program is intended to be supplemented with a volunteer
system to provide coverage after business hours.  However, none of
the communities we visited had yet established a volunteer system
that provided evening and weekend coverage.  Consequently,
beneficiaries using host nation facilities after normal business
hours often obtained that care without assistance.  In response, DOD
has agreed to increase the availability of liaisons to provide
24-hour coverage. 

Effective October 1, 1994, DOD expanded an existing CHAMPUS
initiative to improve access to host nation facilities for active
duty family members.  DOD estimates this initiative will cost
approximately $2.8 million annually.  The expanded CHAMPUS initiative
waives cost sharing for active duty family members who obtain
outpatient and inpatient care at host nation facilities. 
Beneficiaries are pleased and indicated that the elimination of
copayments and deductibles has enhanced their willingness to seek
care at host nation facilities. 

DOD is also planning to use host nation physicians to act as liaisons
and assist military doctors in monitoring beneficiaries admitted to
host nation facilities for care.  The direct involvement of a
physician representing the military may ease beneficiaries' feelings
of being "dumped" when they are referred to host nation facilities. 

To better inform beneficiaries and thereby reduce their anxieties
about health care--military and host nation--available in their
communities in Europe, DOD is creating an education program.  DOD is
also planning to have host nation medical records translated into
English.  This should help ensure that in the future patients will
have an adequate record of previous medical conditions and
treatments. 

To improve beneficiaries' access to dental care, DOD is taking a
number of steps.  First, DOD is striving to efficiently use its
existing dental capabilities, including sharing resources among the
three services.  Second, DOD is increasing the number of dentists,
orthodontists, pedodontists, and other dental support personnel
assigned in Europe.  The Air Force plans to assign an additional 23
general dentists, 2 orthodontists, 2 pedodontists, and 54 dental
assistants to Europe during fiscal year 1995.  As of May 26, 1995,
all but four dentists had arrived overseas.  The Army has contracted
with civilians to fill 22 general dentist, 5 orthodontist, and 10
dental hygienist positions.  Third, at remote locations or areas with
small populations where military dental services may not be
available, DOD plans to arrange for dental care through host nation
providers.  Fourth, family members will be allowed to remain enrolled
in the Dependents Dental Plan while the service member is assigned
overseas.\2 This will permit family members to obtain dental care in
the United States, for example, during stateside visits. 

Finally, over the past year, DOD has made an effort to educate
beneficiaries on the forthcoming changes in Vicenza and to develop a
plan to ensure the availability of quality medical care.  For
example, it has (1) prepared a new detailed handbook to inform
patients about host nation obstetrical services; (2) developed a
questionnaire to obtain beneficiary feedback about host nation
medical care; (3) held meetings with beneficiaries to educate them on
the changes; (4) hired a host nation physician to perform oversight
and liaison services among the host nation facility, the patient, and
the military medical providers; and (5) made arrangements for
translators to assist when Italian ambulance service is needed. 
Several other significant steps are described in detail in a plan DOD
prepared and sent to the Congress in March 1995.\3

In February 1995, an Italian newspaper reported that the hospital in
Vicenza--the primary host nation referral facility--was alleged to
have engaged in poor health care practices.  These practices included
improper disposal of contaminated waste in the emergency room,
operating rooms, and the pathologic anatomy and metabolic disease
sections.  Expired or spoiled medicines were also reportedly
discovered throughout the hospital.  Army medical officials in
Vicenza followed up with hospital administrators and were assured
that U.S.  beneficiaries did not receive expired medicines or have
resultant bad medical outcomes.  Army officials believe the situation
is resolved and that beneficiaries are not at any risk.  They believe
the hospital provides superb care overall.  This incident does,
however, provide sufficient reason for military medical providers to
remain actively involved in their patients' care when they are
referred to host nation facilities.  Army officials recognize this
need and have pledged to actively monitor all patient care in host
nation facilities. 


--------------------
\2 The Dependents Dental Plan covers spouses and children of
active-duty members of the uniformed services.  It is not for active
duty members or retired members.  To be eligible for the Dependents
Dental Plan, dependents must reside in the United States, Guam, the
U.S.  Virgin Islands, or Puerto Rico. 

\3 Report to Congress in Response to Section 733, Defense
Authorization Act for FY95, Delay in Closure of Army Hospital,
Vicenza, Department of Defense (Washington, D.C.:  1995). 


   CONCLUSIONS
------------------------------------------------------------ Letter :7

Military health and dental care professionals are working long hours
attempting to meet beneficiary demands that are greater than military
facilities are staffed to provide.  Even though some of the strain
placed on medical and dental resources may decrease slightly as the
beneficiary population in Europe continues to shrink, the military
medical facilities in Europe will not have the capacity to handle all
care to eligible beneficiaries.  Nor does it appear practical to
staff and maintain enough military medical facilities to meet the
peace-time health care needs of all eligible beneficiaries.  Troops
are widely dispersed and, in some places, too few in number to
provide the workload necessary to justify a full service medical
facility and enable medical staff to maintain their skills. 
Therefore, beneficiaries' use of host nation medical care will
continue and may increase. 

Given these circumstances, the U.S.  military medical leadership
needs to continue to take an active role in attending to and managing
the health care needs of beneficiaries--particularly those who must
rely on host nation care.  An active military role not only will
ensure that beneficiaries receive appropriate care but should also
improve the perceptions that beneficiaries have about host nation
health care. 

DOD has been slow to address the problems confronting military
beneficiaries.  In our view, though, the steps that have been taken
are directed toward alleviating the major concerns of most
beneficiaries.  Because of these actions, we are not making any
recommendations. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

In a letter dated June 20, 1995, the Assistant Secretary of Defense
(Health Affairs) generally concurred with this report.  (See app. 
III.) The letter acknowledged that we accurately described the
problems and the corrective actions under way and planned.  In
addition, DOD officials provided updated information on some of the
actions they are taking, and this has been added to the report. 


---------------------------------------------------------- Letter :8.1

We are sending copies of this report to the Chairman and Ranking
Minority Member, Senate Committee on Armed Services; the Chairman and
Ranking Minority Member, Subcommittee on Military Personnel, House
Committee on National Security; the Secretary of Defense; and other
interested parties. 

This work was performed under the direction of Stephen Backhus,
Assistant Director.  Other major contributors were Timothy Hall and
Barry DeWeese.  Please contact me on (202) 512-7101 if you have any
questions about this report. 

Sincerely yours,

David P.  Baine
Director, Federal Health
 Care Delivery Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

To assess how DOD is meeting the needs of beneficiaries overseas as
the number of military personnel and facilities are reduced, we
visited the following 15 military communities:  Augsburg, Darmstadt,
Frankfurt, Grafenwoehr, Hanau, Heidelberg, Kaiserslautern,
Katterbach, Nuremberg, Spangdahlem, Stuttgart, Wiesbaden, and
Wuerzburg, Germany; and Aviano and Vicenza, Italy.  During these
visits we met with numerous military health officials, including the
commanders of the of the five remaining U.S.  military hospitals in
Germany and northern Italy (four Army and one Air Force).  In
addition, we interviewed 29 physicians representing
obstetrics/gynecology, family practice, pediatrics, orthopedics,
allergy/immunology, psychiatry, ambulatory patient care, internal
medicine, radiology, otolaryngologists, and general surgery.  We also
met with 11 Army and Air Force commanders and staff of outlying
health clinics. 

Because beneficiaries indicated concerns over a lack of access to
U.S.  dental facilities overseas, we interviewed six Army dental
commanders, including three Army dental clinic commanders assigned to
outlying military communities. 

We conducted "round-table" panel discussions to obtain input from
beneficiaries as to changes in the availability of health care.  We
convened 20 panels with a total of 102 beneficiaries in the military
communities we visited in Europe.  Most of the beneficiaries were
active duty members and their dependents.  The beneficiaries were not
randomly selected but were identified by representatives of the
National Military Family Association, Army Community Services, and
Air Force Family Support Centers.  These meetings with (1) military
medical and dental staff and (2) beneficiaries provided the basis for
much of the information contained in this report. 

Both before and after our visit to Europe, we met with officials of
the Office of the Assistant Secretary of Defense (Health Affairs) and
Offices of the Surgeons General to discuss the status of their
actions and plans to meet the health care needs of beneficiaries
overseas.  In addition, we met with representatives of the National
Military Family Association--an advocacy group for military
families--to discuss their concerns about military and host nation
health care in Europe. 

We reviewed documents obtained from military medical officials in the
Office of the Assistant Secretary of Defense (Health Affairs),
Offices of the Surgeons General, and various medical activities in
Europe.  These documents included legislation, policy memorandums,
medical drawdown information, data on beneficiary access to care,
data on military medical staffing in Europe, analyses of beneficiary
complaints, and beneficiary handbooks about military and host nation
medical care. 

We did our work between March 1994 and March 1995 in accordance with
generally accepted government auditing standards. 


U.S.  MILITARY MEDICAL FACILITIES
IN GERMANY AND NORTHERN ITALY
========================================================== Appendix II

The following is a list of all U.S.  Air Force and U.S.  Army medical
facilities operating in Germany and northern Italy as of April 21,
1995.  Air Force facilities are noted with an asterisk. 

HOSPITALS

Bitburg, GM*
Heidelberg, GM
Landstuhl, GM
Wuerzburg, GM
Vicenza, IT

CLINICS

Geilenkirchen, GM*
Ramstein, GM*
Rhein Main, GM*
Sembach, GM*
Spangdahlem, GM*
Aviano, IT*
Augsburg, GM
Babenhausen, GM
Bad Aibling, GM
Bad Kreuznach, GM
Bamberg, GM
Baumholder, GM
Buedingen, GM
Butzbach, GM
Darmstadt, GM
Dexheim, GM
Friedberg, GM
Giebelstadt, GM
Grafenwoehr, GM
Hanau, GM
Hohenfels, GM
Illesheim, GM
Kaiserslautern, GM
Karlsruhe, GM
Katterbach, GM
Kitzingen, GM
Mannheim, GM
Nuremberg, GM
Sandhofen, GM
Schweinfurt, GM
Stuttgart, GM
Vilseck, GM
Wiesbaden, GM
Livorno, IT




(See figure in printed edition.)Appendix III
COMMENTS FROM THE DEPARTMENT OF
DEFENSE
========================================================== Appendix II

