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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 subcommittee 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 hare 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 Serv. ice 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.

The subcommittee recommends that the Department of Defense pursue these and other recommendations of the study on a priority basis and that the Department be prepared to recommend legislation for increasing the level of earnings of military physicians and increasing the general/flag officer billets at least to achieve comparability with Public Health Service and Veterans Administration physicians.

III. CARE OF DEPENDENTS AND RETIREÉS Program Presently Available in Military Facilities

The dependents of active duty members of the uniformed services, retired members and their dependents, and the surviving dependents of deceased, retired and active duty members are all eligible for comprehensive health care on a space-available basis at uniformed services facilities.

Dependents pay $1.75 per day for inpatient care. There is no charge for inpatient care for retired enlisted members. Retired officers pay $1.40 per day for subsistence when hospitalized. There is no charge for outpatient care for any of these groups.

The following table illustrates the extent to which the foregoing groups use military medical facilities:

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10, 376

Total -
Total outpatient visits (in millions):

Active duty dependents--------
Retired members-----
Dependents of retired and deceased members-------

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25.4 The language of the statute which covers the entitlement to care for the foregoing groups (ch. 55 of title 10, United States Code) has the effect of creating a priority system.

Under that system, first priority for care in uniformed services facilities goes to active duty members. The second priority covers the dependents of active duty members and the surviving dependents of deceased active duty members. The third priority covers retired members and their dependents and the surviving dependents of deceased retired members.

While all of these groups are presently accommodated in most military facilities most of the time, as the subcommittee indicated earlier, the dependent and retiree population is increasing constantly and making ever heavier demands on the services of military facilities.

The subcommittee would also point out that dependents and retirees having access to military facilities are able to get care at somewhat less personal cost than those who are cared for in civilian facilities. While the subcommittee supports the long tradition of providing care for dependents and retirees in military facilities on a spacearailable basis, it would point out that some inequity does exist in the level of charges for care between those cared for in military facilities and those who get care from civilian sources.

37-066—70-No. 603

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