GAO-05-64 (Part 1 of 3)

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xeno

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This is the accessible text file for GAO report number GAO-05-64
entitled 'VA and DOD Health Care: Efforts to Coordinate a Single
Physical Exam Process for Servicemembers Leaving the Military' which
was released on November 12, 2004.

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Report to Congressional Requesters:

United States Government Accountability Office:

GAO:

November 2004:

VA and DOD Health Care:

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

GAO-05-64:

GAO Highlights:

Highlights of GAO-05-64, a report to congressional requesters

Why GAO Did This Study:

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.

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.

What GAO Recommends:

GAO is recommending that the Secretaries of VA and Defense develop
systems to monitor and track the progress of VA regional offices and
military installations in implementing single separation exam
programs. VA and DOD concurred with GAO’s findings and recommendation.

www.gao.gov/cgi-bin/getrpt?GAO-05-64.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marcia Crosse at (202)
512-7119.

[End of section]

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:

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:

GAO Comments:

Appendix V: Comments from the Department of Defense:

Appendix VI: GAO Contacts and Staff Acknowledgments38:

GAO Contacts:

Acknowledgments:

Tables:

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

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

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

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:

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.[Footnote 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 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
installations.[Footnote 2]

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 service-
connected disability compensation.[Footnote 3] 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 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.[Footnote 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.

Results in Brief:

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

Background:

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.[Footnote 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.[Footnote 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
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.[Footnote
7]

In addition, the Army, Navy, Air Force, and Marines[Footnote 8] 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.[Footnote 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.
 

xeno

Staff Member
PEB Forum Veteran
GAO-05-64 (Part 2 of 3)

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

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

Military service: Navy/Marines;
During active duty[A]: Physical exams occur every 5 years through age
50, every 2 years through age 60, and annually after age 60;
Completion of active duty tour: Separation exams are not usually
required unless a servicemember does not have a current physical exam
on file; If a current exam is on file, the Navy requires a review
of the servicemember's medical history, documentation of any changes in
health, and a focused exam, if needed;
Retirement: Separation exams are not usually required unless a
servicemember does not have a current physical exam on file; If a
current exam is on file, the Navy requires a review of the
servicemember's medical history, documentation of any changes in
health, and a focused exam, if needed.

Military service: Air Force;
During active duty[A]: Preventive Health Assessments (PHA)[C] occur
annually;
Completion of active duty tour: A separation assessment is required
when the servicemember has not had a PHA within the last year; A
separation exam is required if the servicemember has not had a PHA
within 5 years of scheduled separation[D];
Retirement: A separation assessment is required when the servicemember
has not had a PHA within the last year; A separation exam is required
if the servicemember has not had a PHA within 3 years of scheduled
separation[D]

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).

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

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

[C] During 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.

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

[End of table]

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)[Footnote 10] issued a report
that concluded that annual health assessments, as currently
administered by 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,[Footnote 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 impact on fitness for duty.[Footnote 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.[Footnote 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.

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

* 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.

* 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.

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.[Footnote 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 department-specific
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.

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:

Military installation: ARMY: Fort Drum;
Location: New York;
Single separation exam approach: Sequential;
Number of single separation exams reported in 2003: 922.

Military installation: ARMY: Fort Eustis;
Location: Virginia;
Single separation exam approach: VA contractor;
Number of single separation exams reported in 2003: 28.

Military installation: ARMY: Fort Stewart;
Location: Georgia;
Single separation exam approach: VA contractor;
Number of single separation exams reported in 2003: 38.

Military installation: NAVY: Naval Station Mayport;
Location: Florida;
Single separation exam approach: Sequential;
Number of single separation exams reported in 2003: 450.

Military installation: Total;
Number of single separation exams reported in 2003: 1,438.

Source: GAO analysis of VA information.

[End of table]

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:

Military installation: ARMY: Fort Lee;
Location: Virginia;
Number of single separation exams reportedly delivered in 2003: 76.

Military installation: AIR FORCE: Little Rock Air Force Base;
Location: Arkansas;
Number of single separation exams reportedly delivered in 2003: 237.

Military installation: AIR FORCE: Pope Air Force Base;
Location: North Carolina;
Number of single separation exams reportedly delivered in 2003: 50.

Military installation: MARINES: Camp Lejeune;
Location: North Carolina;
Number of single separation exams reportedly delivered in 2003: 1,712.

Military installation: Total;
Number of single separation exams reportedly delivered in 2003: 2,075.

Source: GAO analysis of VA information.

[End of table]

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.

* 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.

* 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.

* 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.

* 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.[Footnote 15] (See fig.
1.)

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

[See PDF for image]

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.

[End of figure]

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.[Footnote 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.[Footnote 17]

Conclusions:

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.

Recommendations for Executive Action:

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.
 

xeno

Staff Member
PEB Forum Veteran
GAO-05-64 (Part 3 of 3)

Agency Comments:

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.

Signed by:

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

[End of section]

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.[Footnote 18] 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.[Footnote
19] We obtained the separation data from the Defense 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 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.

[End of section]

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

[See PDF for image]

[End of figure]

[End of section]

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

[See PDF for image]

[End of figure]

[End of section]

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

THE SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:

November 1, 2004:

Ms. Marcia Crosse:
Director:
Health Care - Public Health and Military Health Care Issues:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:

Dear Ms. Crosse:

The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VA AND DOD HEALTH CARE:
Efforts to Coordinate a Single Physical Exam Process for Servicemembers
Leaving the Military, (GAO-05-64). VA concurs with GAO's findings and
recommendations. Further discussion and comments are included in the
enclosure.

VA appreciates the opportunity to comment on your draft report.

Sincerely yours,

Signed by:

Anthony J. Principi:

Enclosure:

Enclosure:

DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT, VA AND DOD HEALTH CARE:
Efforts to Coordinate a Single Physical Exam Process for Servicemembers
Leaving the Military (GAO-05-64):

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.

Concur - The Department of Veterans Affairs (VA) concurs with GAO's
findings and recommendation that the Departments of Defense (DoD) and
VA develop a better process to monitor the handling of separating
service members who intend to seek compensation for medical conditions.
The Veterans Benefits Administration (VBA) and the Veterans Health
Administration (VHA) have actions in place or planned that meet the
intent of the recommendation.

In FY 2004, VBA established an inspection process of the Benefits
Delivery at Discharge (BDD) sites to determine compliance with
Compensation and Pension Service BDD procedures. In addition, VA has in
Departmentwide concurrence a revision of the 1998 memorandum of
understanding (MOU) between VA and DOD that established the single
separation examination program. The revised MOU standardizes the single
separation examination process and timeline; defines the target
population; stipulates continuity of the MOU through changes of command
at the military treatment facilities; and requires VA and DOD to work
toward an electronic solution for sharing of information. VBA has
provided its regional offices with copies of the draft MOU and
instructions to initiate discussions with the military treatment
facilities in their jurisdiction in anticipation of the signing of the
new MOU. Regional offices have also been instructed to begin work with
the military treatment facilities on drafting new local MOUs to
implement the provisions of the revised Departmental MOU.

The VA/DoD Joint Strategic Plan, goal 3, objective 3.2, requires VA and
DoD to: "Provide far a seamless transition from active duty to veteran
status through a streamlined benefits delivery process." The VA/DoD
Joint Executive Council (JEC) is revising the plan for FY 2005, which
will include substantive performance measures that the JEC will
monitor.

Additional Comments:

GAO's comments on page 5: "Results in Brief, ...and VA either could not
provide information on program locations or provided us with inaccurate
information."

VA's response: VBA routinely collects information from the regional
offices regarding participation in the Single Examination Process, and
this information was provided to GAO upon request. GAO was advised that
this information was being updated. An updated list was provided to GAO
on May 4, 2004.

GAO's comments on page 6: "...only an estimated 13 percent of service
members 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."

VA's response: The focus of the seamless transition initiative, of
which the Single Separation Examination is one aspect, is to reduce
redundant and/or burdensome practices that complicate the service
member's access to VA benefits; not to realize cost savings for the
military services. Separation examinations are not required for every
service member; however, in the event that a service member intends to
file for VA disability benefits and DoD requires a separation
examination, then the Single Separation Examination Process works to
avoid duplication and unnecessary burden for those service members.

Replace, "consequently, the military services may not realize resources
savings by eliminating or sharing responsibility for this exam." With
"Although these figures do not seem high, the thrust of the proposed
DoDNA accelerated transition examination process is essentially to
allow the service member to receive benefits earlier and with less
inconvenience. By allowing the eligible service member to begin the C&P
process up to 180 days prior to separation, more service members will
receive their benefits at, or soon after, discharge. This will
streamline the transition examination for service members by completing
this process earlier, rather than during the busy transition period, or
after separation - when the service member may be moving or looking for
a job."

(Note: The 180 day provision was not included in the previous MOU.):

GAO's comments on page 12: "in general, VA's C&P exam is more
comprehensive and detailed than the military services' separation
exams."

VA's response: Replace this sentence with, "The VA C&P exam, in
addition to military requirements, may include additional detailed
information to document loss of function."

GAO's comments on page 20: "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 VA
C&P exams to meet their separation requirements and that, as a result,
single separation exams were being provided."

VA's response: VA believed that Pope AFB was using the VA examination
for its separation purposes. Copies of the examination reports were
routinely provided and VA received no negative feedback or complaints.
In April 2004, Pope AFB asked VA to stop sending the exam copies
because they were not being used to replace separation physicals.
During FY 2004, VA received an average of only 11 claims per month from
Pope AFB.

GAO's comments on page 20: "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 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
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."

VA's response: In March 2001, both Camp Lejeune and the Winston-Salem
VA Regional Office signed an MOU specifically implementing the pre-
discharge program and the single examination initiative. At the time of
this signing, VA believed the single separation examination process
would be implemented at separation points in Camp Lejeune. VA has
verified that the Camp Lejeune Hadnot Branch Clinic of the US Naval
Hospital is following the single examination process.

GAO's comments on page 26: "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."

VA's response: The issue for space at the Fort Bragg BDD site has been
revisited. Currently, the Garrison Commander proposes to allocate 7,000
square feet for VA's BDD site with a proposed occupation date of June
2005. Fort Bragg will make a final decision on this proposal by the end
of November 2004.

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

GAO Comments:

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.

[End of section]

Appendix V: Comments from the Department of Defense:

THE ASSISTANT SECRETARY OF DEFENSE:
HEALTH AFFAIRS:

WASHINGTON, D. C. 20301-1200:

NOV 03 2004:

Ms. Marcia Crosse:
Director:
Health Care-Public Health and Military Health Issues:
U. S. Government Accountability Office:
Washington, DC 20548:

Dear Ms. Crosse:

This is the Department of Defense (DoD) response to the GAO draft
report, GAO-05-64, "VA AND DOD HEALTH CARE: Efforts to Coordinate a
Single Physical Exam Process for Servicemembers Leaving the Military,"
October 13, 2004 (GAO Code 290392). The Department concurs with the GAO
draft report. Comments are enclosed.

The Department of Defense (DoD) recognizes a shared DoD/Department of
Veterans Affairs (VA) separation process is beneficial to
Servicemembers and supports our mutual goal of a seamless transition
between the two departments. The current Benefits Delivery at Discharge
program is consistent with that goal. The purpose and scope of the
assessments administered by the military services differ from those
administered by the VA. The VA compensation and pension examination is
used to establish a disability rating which helps to determine the
amount of compensation a veteran receives. The military assessment
evaluates and documents the Servicemember's health and fitness for duty
at the time of separation. DoD and VA are currently coordinating an
updated Memorandum of Agreement (MOA) further facilitating local
cooperation between military treatment facilities and VA facilities to
support the shared separation process. This MOA has been significantly
modified from the version available at the time of the GAO review.

My points of contact for this matter are COL Gary Matteson (functional)
at 703-681-1703 and Mr. Gunther Zimmerman (audit liaison) at 703-681-
3492.

Sincerely,

Signed by:

William Winkenwerder, Jr., MD:

Enclosure: As stated:

GAO-05-64/GAO 290392 "VA AND DOD HEALTH CARE: EFFORTS TO COORDINATE A
SINGLE PHYSICAL EXAM PROCESS FOR SERVICEMEMBERS LEAVING THE MILITARY:

DEPARTMENT OF DEFENSE COMMENTS TO THE RECOMMENDATION:

RECOMMENDATION: The GAO recommended that, to determine where single
separation examination programs are established and operating, the
Secretary of Veterans Affairs 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 Benefits
Delivery at Discharge sites (Page 29/Draft Report).

DoD RESPONSE: Concur. The capability to monitor and track progress of
program implementation has been hampered by the lack of a shared VA/DoD
information technology system. Currently, the military facilities
report this information manually to their Services. The VA is
developing automated reporting tools and will be doing on-site visits
to the BDD sites. VA and DoD will share this information.

[End of section]

Appendix VI: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

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

Acknowledgments:

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

FOOTNOTES

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

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

[3] This 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.

[4] We 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.

[5] Servicemembers 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.

[6] DOD'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.


[7] The 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, § 706(b),
118 Stat. 1773, (amending 10 U.S. C. § 1145(a)).

[8] The Marines follow the Navy's requirements.

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

[10] The 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.

[11] The U.S. Preventive Services Task Force was established by the
U.S. Public Health Service in 1984 as an independent panel of experts
to review the effectiveness of clinical preventive services.

[12] Determining 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.

[13] See Veterans' Benefits Improvements Act of 1996, Pub. L. No. 104-
275, § 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.

[14] However, 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.

[15] According 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.

[16] Military commanders typically rotate about every 3 years.

[17] However, 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.

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

[19] Little 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.

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