approximately $200 million. As indicated further in this report, the claims would have been higher if more people had been made aware of their rights under CHAMPUS.

Background of Committee Interest

The Committee on Armed Services has long shown a special concern for the medical care of military personnel and of their families. In this regard, the work of two prior subcommittees should be mentioned.

In 1964 the work of the Special Subcommittee on Construction of Military Hospital Facilities led to significant improvements in the Department of Defense' medical construction policies, particularly with respect to the programing of beds in new military hospitals for retired members and their dependents, a type of programing which had been discontinued by the Secretary of Defense in 1962.

In 1967 the Special Subcommittee on Military Dental Care was established for the purpose of inquiring into "the dental care needs of military families, the importance of this type of care to military personnel, the best way to provide care if needed, and the cost of such a program." While the legislation to authorize a civilian dental care program for the dependents of active duty members, which the subcommittee recommended, has yet to be submitted to the Congress by the Department of Defense, significant improvements in the military dental care program for dependents did result from the subcommittee's work. Moreover, much valuable information on this subject was developed by the subcommittee which will materially assist both the Committee on Armed Services and the Department of Defense in eventually developing a solution to the dependent dental care problem. Hearings and Witnesses

The subcommittee held 3 days of hearings in Washington, D.C., and, in addition, had the benefit of several other studies of the Defense Department medical programs.

Of the six principal departmental witnesses requested by the subcommittee, only two-the Surgeon General of the Air Force and the Director of OCHAMPUS-appeared. The other four, however, were represented by high-level members of their respective staffs who assured the subcommittee that they were authorized to speak for their principals and their respective departments on all matters before the subcommittee.

Testifying on behalf of the Office of the Secretary of Defense were Brig. Gen. George J. Hayes, USA, Staff Director, Office of the Deputy Assistant Secretary of Defense for Health Affairs; Brig. Gen. Leo E. Benade, USA, Deputy Assistant Secretary of Defense for Military Personnel Policy; Mr. John C. Broger, Director, Office of Information for the Armed Forces; and Mr. Vernon McKenzie, Health Administrator, Office of the Deputy Assistant Secretary of Defense for Health Affairs.

Other Department of Defense witnesses were: Lt. Gen. Kenneth E. Pletcher, USAF, Surgeon General of the Air Force; Rear Adm. John W. Albrittain, USN, Deputy Surgeon General of the Navy; Brig. Gen. Thomas J. Whelan, Jr., USA, Acting Surgeon General of the Army, and Brig. Gen. Louis J. Hackett, Jr., USA, Director of OCHAMPUS.

Also testifying or supplying statements for the record were officials of the Fleet Reserve Association, the American Optometric Association, the Reserve Officers Association, the Retired Officers Association, and the Air Force Sergeants Association. Two Navy dependents, Mrs. Gladys E. Ford and Mrs. Elizabeth Evans, appeared at their own request to present a petition from service wives in behalf of a dependent dental program.

II. HEALTH CARE OF ACTIVE DUTY PERSONNEL

Program Presently Available

Active duty members are provided any type of medical care they require, with no restrictions, in facilities of the uniformed services. There is no charge for outpatient care and no charge for inpatient care for enlisted patients. Officer inpatients pay a nominal charge (currently $1.32 per day) for subsistence while hospitalized.

On an average day in fiscal year 1969 there were 31,710 beds occupied in military hospitals by active duty members. During that same year active duty members made approximately 28 million outpatient visits to military facilities.

Quality of Care

To the extent that such a determination could be made, it is the conclusion of the subcommittee that the quality of care provided in military hospitals and facilities is excellent. General Hayes, representing the Deputy Assistant Secretary of Defense for Health Affairs, testified that his office had no concern about the quality of care in military facilities and that there were no areas in which there were inadequacies affecting the quality of care.

Similarly, there was no evidence brought to the attention of the subcommittee of any breakdown of the quality of care within military facilities. In any system as large and diversified as the armed services medical program, Members of Congress do hear from time to time complaints of inadequate care, usually resulting from the inability of a member of the service to get the care which he feels he requires. There have been from time to time individual cases where care was denied when it should not have been or where care was improper or inadequate. Whenever such cases are brought to the attention of the Armed Services Committee, they are immediately made known to the Department of Defense. On the whole, however, the committee can say that the quality of care provided to members of the Armed Forces has been thorough and excellent and matches or exceeds the standards of care provided to any other segment of the population. However, General Hayes has further testified that looking to the future, if the problem of retention of hard-core Medical Corps officers continues, there is a possibility that the quality of medical care will deteriorate. This problem of retention of career officers is discussed further on in this report.

Another factor which concerns the subcommittee as to the longrange effect on the quality of care is the crowded condition existing in many hospitals and other medical facilities today as they attempt to accommodate an ever-increasing dependent and retired population. While it is recognized that the hospitals are particularly hard-pressed today due to the additional demands generated by Vietnam, the sub

committee would say that, even so, some thought may have to be given in the future to further limiting the use of military facilities by dependents and retirees.

Care of Active Duty Personnel by Civilian Doctors and Hospitals

Active duty members may also obtain health care from civilian physicians and hospitals in an emergency-such as while in a leave or travel status or when the distance between their place of duty and the nearest Federal facility is such that it would be more economical for the Government to obtain the care locally. There is no cost to the member for care of this type unless the care is obtained while in an "absent without leave" status.

The cost to the Government for civilian care for active duty members for fiscal year 1969 amounted to approximately $11 million.

A number of complaints have reached the subcommittee regarding the difficulties which civilian physicians and hospitals encounter in attempting to have their bills paid for care provided active duty members. After examining into this subject, we are surprised that the number of complaints has not been much greater.

It is difficult for a civilian physician or hospital to obtain information on how these systems operate and apparently even more difficult for them to actually get their bills paid.

The subcommittee had brought to its attention a number of cases where doctors have had extraordinary difficulty in collecting small medical bills. One example will suffice to illustrate the problem:

Two doctors in Texas performed service for a man in June and began submitting bills to the Army without results. When the third bill went out, all copies of it were returned, together with a form letter that told the doctors if they wanted to know the serviceman's whereabouts, they could get the information for a $1.50 fee payable in advance. This letter with the copies of the bills arrived in the doctors' office in December, 6 months after the service was performed. The doctors were finally paid the following April.

The Army operates a small system for the payment of bills for active duty members under which more than 30 different offices are charged with responsibility for payment of the bills in question.

The Navy operates its own system for its active duty members, with responsibility for discharging the bill paying function resting primarily with medical administrative officers in the various naval district headquarters.

The Air Force likewise operates its own system, with responsibility vested in hundreds of different bases throughout the United States. In addition to these three systems, there is, of course, one major system which handles over $200 million a year in billing. This is the CHAMPUS system, which is much more efficient—at least in getting the bills paid.

The principal OSD witness, General Hayes, conceded that, from a medical management standpoint, this proliferation of systems leaves much to be desired. General Hayes disclosed that the four systems have recently been merged into one system for the payment of bills covering care obtained in Europe, Africa, and the Middle East. This was done on a pilot basis, and the results are to be evaluated this year, at which time a decision would be made as to whether a merged system would be feasible in the United States.

The subcommittee strongly supports the single system concept and urges the Department of Defense to adopt it worldwide, provided no serious difficulties are encountered in the pilot study in Europe.

Care of Civilian Employees

Military hospitals and medical facilities also provide care under certain circumstances for civilian employees, chiefly overseas.

U.S. civilian employees overseas and their dependents are provided care on a space-available basis at military facilities. They are charged for such care at rates prescribed annually by the Bureau of the Budget. For example, the current charge for inpatient care is $53 per day.

Civilian employees in the United States who suffer occupational injury or illness are also provided care in military facilities in limited circumstances.

Promotion of Public Health and Physical Fitness

The Defense medical establishment also provides other important health services to the military community. These include prevention and control of diseases and injuries through the application of principles of sound public health, an occupational health program to protect military personnel and civilian employees from health hazards in their working environment, and programs to encourage personnel health maintenance and physical fitness. In the latter regard, 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, which looks toward improving the physical fitness of all personnel.

Finally, the Department of Defense performs important medical and health related research oriented toward the prevention and treatment of disease and health hazards that are a particular threat to combat forces.

Retention of Medical Officers

The Surgeon General of the Air Force, General Pletcher, and the spokesmen for the Surgeons General of the Navy and the Army all testified that the retention of career medical officers was the most serious problem now confronting their medical service. General Hayes, speaking for the Department of Defense, said that retention of career doctors is the biggest medical problem the Armed Forces face. When asked whether he had any concern about the quality of care in military facilities, General Hayes replied as follows:

At the particular moment, no. We are concerned in a few specialty areas where there is a shortage of people.

If we continue to have the problem of retention of our hard-core career medical officers, there is a possibility that the quality of medical care will deteriorate. The seriousness of this problem is illustrated by the following statistics. During the 6-month period from April through October of last year, 436 career Medical Corps officers resigned or retired from service. Of those who were eligible to retire or resign during that period, only 39.7 percent remained on active duty. Or, put another way, 60.3 percent of those career Medical Corps officers who were free to leave the service during that period did so.

It is clear to the subcommittee that the career medical officer struc

ture cannot long survive such a loss rate and that all reasonable actions which might significantly reduce these losses must be taken by the Congress, the Department of Defense, and the military departments.

THE HÉBERT BILL

General Hayes expressed the opinion of the Deputy Assistant Secretary of Defense for Health Affairs that from the long-range standpoint one of the most important steps that could be taken toward improving medical officer retention-and, hence, the quality of medical care is the enactment of H.R. 1, the legislation proposed by the Honorable F. Edward Hébert, of Louisiana, which would establish a uniformed services health science academy. The academy would improve the retention of military medical officers because of the opportunity for academic recognition, academic status, and for expanding professional knowledge. Doctor Hayes said his office has developed an implementation plan for H.R. 1 that it believes would be acceptable to the American medical community.

The subcommittee recommends the enactment of H.R. 1 and urges the Armed Services Committee to commence hearings on the legislation in this session of Congress.

SHORT-TERM SOLUTIONS

A study ordered by the Deputy Assistant Secretary of Defense for Health Affairs, Dr. Louis Rousselot, looked into the factors relating to early retirement and/or resignation of career physicians. The study, completed last year, was done by Lt. Col. Gilbert Jacox, Medical Service Corps, U.S. Army.

The study, which incorporated the findings of all previous such studies back to 1956, found that the 14 factors most affecting medical officer retention were, in descending order of importance, instability of assignment, salary, career management, housing, personal freedom, promotions, professional training and continuing education, assignments, professional leadership, family life, prestige, undesirable location or facilities, quality of medical care, and physician-patient relationship.

The subcommittee would note that the quality of medical care and the patient-physician relationship were the lowest rated among all the reasons for dissatisfaction with the medical service. The subcommittee would also note that most of the reasons listed can be attacked administratively by the Department of Defense without resorting to legislation.

One of the most important conclusions of this excellent survey, in the subcommittee's opinion, is that no one solution will overcome the problems involved but that a number of related steps are required. The subcommittee believes that, consistent with assignment requirements of Vietnam, each of the medical services could make a greater effort to improve the assignment stability of its medical officers.

The subcommittee understands that the Department of Defense has developed plans for other significant actions, such as major improvement in the medical management, attendance at medical meetings, provision of clerical and other support, et cetera.