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PSYCHIATRIST REFUNDED $11,121.75 OCHAMPUS has developed “physician profiles” in an attempt to insure that excessive payments are not being made by the Government.

The subcommittee developed information as to unusually large payments to single physicians under the program to assure that procedures were appropriate for determining the reasonableness of charges. The following table lists by State physicians who were paid over $20,000 by CHAMPUS during calendar year 1968.

NUMBER OF INDIVIDUAL PHYSICIANS AND CLINICS PAID OVER $20,000 BY THE CIVILIAN HEALTH AND MEDICAL

PROGRAM OF THE UNIFORMED SERVICES (CHAMPUS) DURING CALENDAR YEAR 1968

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1 $153,000 paid by CHAMPUS, $23,000 paid by CHAMPUS beneficiaries, for a total of $176,000.

The one doctor who received $176,000 in 1 year is a psychiatrist in San Diego, Calif. OCHAMPUS indicated, in response to inquiry from the subcommittee, that a surveillance is maintained in cases of large payment such as this to make sure no improper payments were made and that some cases had been submitted to the State medical association for investigation. However, a year after the close of calendar 1968, there had been no report back on this particular case and apparently no strenuous effort on the part of DOD representatives to get a determination. The subcommittee was concerned about the long delay in determining the propriety of such payments and pointed out to the Defense Department that if improper payments were involved, they might be continuing through all of calendar year 1969 as well.

The Defense Department initially started inquiry into the case in question in the spring of 1969. The subcommittee finally received a report from the Department of Defense in May of 1970. The delay in receiving this information contributed to the delay in issuing the subcommittee's report.

As a result of the investigation and review, the psychiatrist in ques

tion has refunded to the Government $11,121.75 of the amount paid to him during calendar year 1968.

The subcommittee is concerned that the matter did not appear to be vigorously pursued until the subcommittee showed an interest. The subcommittee has asked the Department of Defense for a review of cases of possible excessive payments in calendar year 1969, and it is hopeful that these can be received by the end of 1970.

It is the recommendation of the subcommittee that the Department of Defense revise its procedures to assure a more current review of the propriety of charges.

IV. DENTAL CARE

There is presently no program of regular dental care for military dependents and military facilities are specifically prevented by law from providing dental care for dependents except outside the United States, or at remote locations where adequate civilian facilities are unavailable, or in emergency cases.

Retired members of the Armed Forces are provided dental care on a space available basis worldwide in facilities of the armed services. For all practical purposes dental care is nonexistent in some areas for retirees.

Only an extremely limited amount of dental care for dependents is authorized from civilian dentists under the CHAMPUS. Such care is limited to (1) care required as a necessary adjunct to medical or surgical treatment and (2) care required by a seriously handicapped dependent of an active duty member which is necessary to correct or improve the handicapping conditions.

In the 90th Congress the Special Subcommittee on Military Dental Care conducted extensive hearings on the question of dental care for military dependents and concluded that the dental care needs of such dependents were not being adequately met and in instances where they were being met were resulting in significant financial hardship. The subcommittee recommended establishing a program of dental care modeled after the CHAMPUS program which would have provided for the major portion of care coming from civilian sources with the dependents paying a portion of the cost and the Government paying the remainder, such as is the case with medical care. Legislation recommended by the subcommittee was not considered in the 90th Congress due to a combination of budgetary restraints and footdragging by the Department of Defense. Present Level of Care

Although care is limited to emergency cases, dependents outside the United States, and those in the approximately 100 areas in the United States designated as “remote areas” because of inadequate civilian facilities, Defense witnesses testified that the space available care provided to dependents is appreciable.

The following table indicates the percentage of the dental work performed on dependents in military facilities.

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The subcommittee would make two particular points about this care. First is the people who get it do not pay anything for it. So, in effect, there is an inequity in that a certain percentage of military dependents get dental care completely free of charge and certain other dependents do not get any care at all. As long as the present procedure is continued, it continues an inequity. The other unfortunate development is that service families tend to plan their dental care around their overseas assignments, which can create additional health problems as pointed out in the following colloquy from the subcommittee hearings:

Mr. FORD. Now, we had testimony in 1966 to the effect that people in the serr. ice, when their children need dental care, delay giving them the care, knowing they have orders to Europe coming in a year or so and they wait until they get over there and then they go get the care because it is free that way. From a medical standpoint as a doctor, you wouldn't recommend that kind of procedure, would you?

General HAYES. No, not at all. Mr. Ford. It is a very bad way to take care of your health care, isn't it? General HAYES. That is correct. It also does something else. You may end up with the situation where the initial care that was needed at the time when the decision was made could have been relatively simple, and relatively short in application and relatively cheap. However, when you get to the place overseas that you referred to you may have a complicated problem, needing care that is both extensive and expensive. So it is a pennywise and poundfoolish situation.

The subcommittee would also point out the fact that in overseas areas there is sometimes a long wait for care or a lack of some types of care available. Inconsistent Position of Department of Defense

At the time of the dental care hearings in the 90th Congress, the Defense Department reserved its position on such a program and indi

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cated it was conducting a survey to discover the extent to which dental care was required.

Of particular significance is the following statement made by the principal Department of Defense witness, then Assistant Secretary of Defense for Manpower, Thomas D. Morris, during those hearings:

No matter what conclusion we draw from the compensation study, we must be sure that the family that is disadvantaged by reason of location or unavailability of service is given an additional benefit * * *

During the study by the present subcommittee, information was received regarding the results of the survey, the highlights of which were as follows:

1. The transient status of military families generates difficulties, both in the selection of civilian dentists and in execution of a treatment program.

2. Dependents of military personnel in the lower enlisted ranks had serious difficulties in obtaining dental care.

3. The cost of dental care is the greatest single obstacle to the fulfillment of dependent dental care needs. For example, 25 percent of the military respondents stated that in their view their dependents did not get the dental care they had needed the previous year. Of these respondents, 82 percent cited cost as the main reason why adequate care was not

obtained. It is unmistakably clear from the above that the results of the survey fully support the findings of the Subcommittee on Military Dental Care and that, on the basis of the above-quoted statement by the Assistant Secretary of Defense for Manpower, the establishment of such a program is fully justified even by the Department of Defense's own criteria.

During the hearings in the 90th Congress, the Department of Defense also indicated that another reason for reserving its position was to await the completion of its quadrennial study of military compensation. That study has still not been completed and submitted to the Congress.

However, the Department of Defense has now taken a position in opposition to legislation authorizing a civilian dental care program for dependents. In other words, there were two reasons for the Department reserving its position. In one case the results fully justified a dental care program according to criteria laid down by the Department itself as well as that indicated by the Dental Care Subcommittee. In the other case, the results the Department was waiting for never have been forthcoming. Nevertheless, the Department, with incomprehensible inconsistency, has now hardened its position and come out in opposition to a dental care program.

The Department's opposition to a dependent dental care bill appears to be based in part on the fact that it is an expensive fringe benefit that would only benefit those members who had dependents. As stated by the Deputy Assistant Secretary for Manpower, to the extent that funds are spent on fringe benefits for some, it limits the amount of increased compensation that can be given to all. The subcommittee appreciates that fringe benefits do not always benefit all personnel equally. But the subcommittee would say that such a simplistic approach cannot be justified with such an essential fringe benefit as

medical care and that the separation of dental care from other legitimate health care needs is unjustified and artificial. This is particularly true in view of the criteria laid down by the Defense Department itself; namely, that personnel should not be especially disadvantaged in obtaining care because of being in a location where they would not be except for orders of the Government.

The Defense Department dental care survey, which will be found in the subcommittee's hearings, is very illuminating. Both the statistics and the comments submitted by military personnel show that there is a great need that is not being fulfilled. The comments section includes many examples similar to the following from an enlisted man with four children:

My wife and children are in need of dental care, which I plan to start. I estimate it will cost me $3,000 over the next 2 years. That figures to be about one-third of my income.

To the subcommittee it is wholly illogical that we would cover people for minor medical attention which costs only a small part of one's monthly pay but provide no help for more serious health care needs which could take as much as one-third of a man's income. Lack of Consideration for Professional Opinion

The subcommittee is particularly disturbed that in arriving at its position the Department of Defense almost completely ignored the advice of its health professionals who are responsible for setting policies concerning the health care of members of the armed forces.

The subcommittee believes that it is particularly significant that all of the Surgeons General personally support the need for and desirability of dental care legislation.

Similarly, General Hayes, speaking for himself and Doctor Rousselot, the Deputy Assistant Secretary of Defense for Health Affairs, testified:

Dental care is part of health care and if you separate the two it's an illogical dichotomy. Our position would be that if we give medica re, we should give denticare from the professional health aspect.

General Hayes agreed under questioning that dental care is the one big gap in the medical program for dependents of service personnel. Position of the American Dental Association

Another development which the subcommittee believes is significant is the changed position of the American Dental Association.

When testifying in the 90th Congress, the American Dental Association took no position for or against a dependent dental care program but said it would have no objection to an adequate one that was professionally sound in structure.

There has since been a change in that policy because of the actions of the ADA House of Delegates. The association has informed the committee that, “The present policy of the American Dental Association is one of positive support for the enactment of an armed forces dependent dental care program.”

In other words, the ADA position has advanced from one of neutrality to one of favoring a dental care proposal. The kind of dental care program recommended by the Dental Care Subcommittee in the 90th Congress would have met the test of professional soundness made by the ADA, namely, that there be some cost sharing by patients and dental care secured from civilian sources.

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