[H.A.S.C. No. 91-60]

REPORT OF SUBCOMMITTEE ON SUPPLEMENTAL SERVICE BENEFITS ON HEALTH BENEFIT PROGRAMS OF THE ARMED FORCES

Summary of Findings, Conclusions, and Recommendations

1. The quality of care provided in military hospitals and facilities is excellent. Two problems exist which in the future could have an adverse effect on the quality of care. These are: the retention of career medical officers; and crowded conditions existing in many hospitals and facilities due to an ever-increasing dependent and retired population.

2. Civilian hospitals and physicians have encountered difficulty in getting their bills paid in cases where they provided care for active duty military personnel in a leave or travel status. Each service maintains a separate system for handling such bills, with confusing procedures and inadequate information provided to doctors. The subcommittee supports the approach, now being tried on a pilot basis in Europe, of having a single system handling the billing for all such civilian care for active duty personnel.

3. Maintaining physical fitness of Armed Forces personnel is an important function of the military medical departments. The subcommittee commends the outstanding physical fitness program of the Department of the Air Force and believes the other services should consider adopting a similar program.

4. The retention of career medical officers is the most serious problem now confronting the military medical departments. The Surgeons General of the Army, the Navy, and the Air Force all agreed on this fact.

All reasonable actions must be taken which might significantly reduce the loss of career medical officers. No one solution will eliminate the problem. Many improvements could be made by the Department of Defense and the military departments administratively.

As a part of the long-range solution to the problem, the subcommittee recommends the enactment of the Hébert bill, H.R. 1, which would establish a Uniformed Services Health Sciences Academy.

To achieve more immediate results, the subcommittee recommends that the Department of Defense pursue on a priority basis all administrative actions which could have a favorable impact on medical officer retention, such as improved career management, greater assignment stability, more adequate support personnel, and more continuing educational opportunities. The subcommittee recommends further that the Department be prepared to submit legislation to increase the level of earnings for military physicians.

5. The dependent medical care program, which provides care by civilian hospitals and physicians to dependents of military personnel, is known as the Civilian Health and Medical Program of the Uniformed Services and referred to by the acronym CHAMPUS. The subcommittee considers the choice of this acronym unfortunate, as its meaning is not immediately apparent to the uninitiated beneficiary as is the case with such terms as medicare. The subcommittee recommends the Department of Defense commence a vigorous program to make military personnel and their families better acquainted with the meaning of CHAMPUS.

6. The CHAMPUS benefits were greatly expanded by the Congress in 1966. The program, however, has not been of as much benefit to military families as Congress intended because of serious shortcomings in the administration of the program.

7. All evidence available to the subcommittee indicates that the quality of care provided to military dependents from civilian sources is excellent. Spokesmen for various military groups who represent more than 200,000 personnel, active and retired, officer and enlisted, all reported that they received virtually no complaints about the quality of care under CHAMPUS.

8. The subcommittee believes that the impact of the administrative problems associated with the expansion of CHAMPUS since 1966 could have been greatly lessened by more adequate advance planning. The subcommittee found planning to be inadequate, although 5 months before the expanded program became law the Assistant Secretary of Defense for Manpower specifically requested the Department of the Army, which is responsible for the dependent medical care program, to prepare appropriate plans for the implementation of the expanded program. Similarly, the subcommittee found that some worthwhile solutions recommended in the studies undertaken since 1966 have not been instituted and the problems to which they address themselves remain unsolved.

9. The physical location of the Office of the Civilian Health and Medical Program (OCHAMPUS) in Denver makes it difficult, timeconsuming, and expensive for that office to deal with the seven uniformed services, all of which are headquartered in Washington. OCHAMPUS' organizational location in the Surgeon General of the Army's office hampers its effective relationship with various organizations, private and governmental, with which it has to deal and leaves it five echelons removed from the office principally responsible for formulating the policies under which it operates that is, the Office of the Assistant Secretary of Defense for Health Affairs and Environment. The subcommittee recommends that OCHAMPUS be redesignated as a DOD agency and be relocated to a suitable location within a 100-mile radius of Washington. The subcommittee also recommends that personnel staffing in adequate numbers be provided for CHAMPUS in the Office of the Deputy Assistant Secretary of Defense for Health Affairs and, while CHAMPUS remains an Army agency, in the office of the Army Surgeon General.

10. Contributing to the administrative problems of OCHAMPUS and fiscal agents and the anguish of potential beneficiaries is the unduly complicated claims form. Some 22 percent of all claims are still being returned to the beneficiaries for correction or additional infor

mation. The subcommittee believes the CHAMPUS claims form can be simplified and recommends that such a restructuring be undertaken, together with the provision of a more lucid instruction sheet.

11. The single most important reason why military dependents are not getting the benefits they are entitled to under CHAMPUS is the lack of a proper information program. Many young enlisted families, who need the program most, are entirely unaware of the benefits Congress has voted for them. The subcommittee found inexcusable delays in publishing information, a lack of understanding as to who was responsible for the information program at all, inadequate distribution of the material published, and the failure of the material published to provide completely authoritative and clearly written explanations.

The subcommittee found that the Head of the Office of Information for the Armed Forces, the principal Defense official responsible for disseminating troop information, was unaware until it was brought to his attention by the subcommittee of Army surveys which indicated as many as 40 percent of the enlisted personnel did not know about the CHAMPUS program.

The lack of an adequate information program on CHAMPUS handicaps the providers as well as the users of care.

The subcommittee recommends that the Department of Defense issue directives clearly setting out the responsibility by agency for the various functions associated with the CHAMPUS information program and providing authority for one official to make sure these functions are carried out. The subcommittee further recommends that a rigorous information program be pursued on a continuing basis with improved written material and use of all available media, including Armed Forces radio and TV facilities, troop newspapers, and the public press, with distribution of material sufficient to make an authoritatire pamphlet available to each military family as well as to those engaged in providing care.

12. Inquiry into the appropriateness of physicians' fees disclosed that one physician, a psychiatrist in San Diego, Calif., received $176,000 in 1 year (1968) under the CHAMPUS program. The subcommittee found that 1 year later OCHAMPUS standard review procedures had failed to produce any report on the appropriateness of the physician's charges. Under prodding by the subcommittee, the Department of Defense pursued an investigation which eventually resulted in the psychiatrist being required to refund $11,121.75 to the Government. The subcommittee recommends that the Department of Defense revise its procedures to assure more current review of the propriety of physicians' charges.

13. It is the conclusion of the subcommittee that the time has come for establishment of a civilian-sources dental care program for dependents of active duty personnel. The position of the Department of Defense in opposing such a program is indefensible and untenable. The subcommittee is particularly disturbed that in arriving at its position, the Department of Defense ignored the advice of its health professionals who are responsible for policies concerning the health care of its personnel.

A dental care survey by the Department of Defense supports the findings of an earlier Armed Services Subcommittee that dental

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care is the one big remaining gap in the medical care program for dependents of service personnel.

The American Dental Association, which took a neutral position on the dependent dental care program during the 90th Congress, has now adopted a policy of positive support for such a program.

The subcommittee recommends in the strongest possible terms that dental care legislation be considered by the Committee on Armed Services at the earliest practicable time.

14. The subcommittee found incredible inconsistencies in the staffing policies of the various services for optometry officers. The subcommittee believes that the ratio of optometry officers in the Army, Navy, and Air Force is inadequate. The subcommittee recommends that pending legislation to provide special pay for optometry officers be made the subject of hearings by a legislative subcommittee.

Dependents and retirees have to wait long periods--often a matter of months-for eye examinations in military facilities. Eye examinations are presently excluded by law under the CHAMPUS program. The subcommittee believes that the law should be changed to include eye examinations in the CHAMPUS program.

15. An inequity results from a policy now in force which excludes personnel retired for physical disability from receiving care in military facilities for certain chronic conditions. The retiree in such cases is required to use VA hospitals, although a military facility capable of providing the needed care may be located much closer to his home. The subcommittee recommends that the policy spelled out in Executive orders be amended so that retired members who are eligible for care in military facilities should be equally eligible for all types of care.

16. The subcommittee commends the Department of Defense for establishing the short-term health insurance program for servicemen being separated from active duty other than by reason of retirement. The insurance during the post-service period covers the discharged man during the period prior to the time he can obtain health care coverage such as might be provided by a new civilian employer. The subcommittee recommends that the Department of Defense take steps to assure better supervision of the program at unit and separation activity levels so the full value of the program will be available to the young families for whom it is intended.

Subcommittee Mandate

I. INTRODUCTION

The Subcommittee on Supplemental Service Benefits was created to conduct an inquiry into the supplemental service benefits, other than exchanges and commissaries, in an effort to ascertain the extent of their use by service personnel and their dependents, their value to service personnel, and a comparison of such supplemental service benefits with industry and Government benefits. The subcommittee's mandate was not to consider specific legislation, but to inquire into and make recommendations regarding possible extensions, expansions, restrictions or improvements in the supplemental benefits available to members of the armed service and their dependents, retired personnel, and dependents of retired and deceased personnel.

First Area of Inquiry

The subcommittee chose as its first area of inquiry a review of the health benefits program of the Armed Forces. The subcommittee gave first priority to health care for service personnel and their families both because its unquestioned importance makes it the No. 1 supplemental benefit and because it provides the first opportunity for congressional review of the health benefits program since the Congress expanded the program by the passage of Public Law 89-614, which became fully effective on January 1, 1967. Public Law 89-614 increased the range of medical benefits available to dependents, provided principally through the provision of outpatient care for the first time from civilian sources, extended civilian hospital and outpatient care to retirees and their dependents, and established a handicapped care program for dependents of active duty personnel.

Magnitude of Programs Reviewed

In approaching a discussion of the problems in the medical programs administered by the Department of Defense, it is necessary to appreciate the size of these endeavors. Some statistics will convey an idea.

The total programs administered by the Department of Defense cover, to a greater or lesser extent, 10 million eligible persons. The Defense Department budget for medical care is $2,700,000,000 a year. The military departments run 240 hospitals and 565 dispensaries which in 1969 had an average daily bed occupancy of 43,610 and handled 53.3 million outpatient visits. There were 1.2 million hospital admissions during 1969 and 146,145 live births in military facilities.

During the year there were 7.4 million dental procedures performed. In addition to this, there is the civilian health and medical program of the uniformed services (CHAMPUS), which administers the care provided to military dependents and retirees and their dependents by civilian hospitals and civilian doctors. In 1969 the CHAMPUŠ program handled claims for 600,000 people at a cost of