This is the accessible text file for GAO report number GAO-05-890R entitled 'Defense Health Care: DOD Has Established a Chiropractic Benefit for Active Duty Personnel' which was released on September 6, 2005. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. September 6, 2005: The Honorable John Warner: Chairman: The Honorable Carl Levin: Ranking Minority Member: Committee on Armed Services: United States Senate: The Honorable Duncan L. Hunter: Chairman: The Honorable Ike Skelton: Ranking Minority Member: Committee on Armed Services: House of Representatives: Subject: Defense Health Care: DOD Has Established a Chiropractic Benefit for Active Duty Personnel: The Floyd D. Spence National Defense Authorization Act for Fiscal Year 2001 (NDAA 2001) directed the Department of Defense (DOD) to develop and implement a plan to make a chiropractic benefit available to all active duty personnel in the U.S. armed forces.[Footnote 1] The practice of chiropractic focuses on the relationship between structure (primarily, the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health. In August 2001, DOD submitted to Congress an implementation plan that described how it planned to develop a chiropractic benefit within the military health system. The plan addressed patient eligibility, access to care, the location of chiropractic clinics, projected costs, staffing, and the marketing and monitoring of the benefit. The NDAA 2001 directed DOD to develop the implementation plan in consultation with the Oversight Advisory Committee (OAC), which was established by the National Defense Authorization Act for Fiscal Year 1995 (NDAA 1995). The OAC was directed by the NDAA 1995 to oversee a 3- year DOD chiropractic demonstration project at no fewer than 10 military treatment facilities (MTF).[Footnote 2] The NDAA 1995 directed that the OAC include the Assistant Secretary of Defense for Health Affairs; the Surgeons General of the Army, the Air Force, and the Navy; and at least four representatives of the chiropractic profession; and also directed that we serve as a member of the OAC.[Footnote 3] As a member of the OAC, we attended meetings of the OAC and provided technical input and advice. The NDAA 2001 also mandated that we monitor the development and implementation of DOD's chiropractic health care plan. As agreed with the committees of jurisdiction, we reviewed the implementation of DOD's chiropractic benefit.[Footnote 4] To review the implementation of DOD's chiropractic benefit, we examined relevant legislation, statutes, and reports containing congressional directives to DOD for establishing and enhancing the chiropractic benefit as well as those directing earlier chiropractic demonstration projects. We reviewed DOD's February 2000 Final Chiropractic Health Care Demonstration Program Report and DOD's August 2001 Report on Chiropractic Health Care Implementation Plan (implementation plan). We also reviewed pertinent DOD policies and procedures, and communications between the services and the TRICARE Management Activity (TMA), the office responsible for ensuring that DOD's health policy is implemented. We collected workload, staffing, and financial data from fiscal year 2002 through fiscal 2004 from each of the MTFs that have established chiropractic clinics. Although we did not independently verify the data that we collected, we queried representatives from each of the services to review the systems used for collecting and maintaining the data. We determined that the data were adequate for our purpose. We interviewed officials from the TMA, the Offices of the Surgeons General of the Air Force, Army, and Navy; and officials and chiropractors from five MTFs that have chiropractic clinics. We also interviewed an official from Cherokee Nation, a company that contracts chiropractors to work in chiropractic clinics for the Army and Air Force. We conducted our review according to generally accepted government auditing standards from October 2004 through August 2005. Results in Brief: To implement its chiropractic benefit, DOD has opened chiropractic clinics at 42 of its 238 MTFs, worldwide, and does not plan to add any additional clinics at this time. All of DOD's 1.8 million active-duty personnel are eligible for the benefit. The 42 chiropractic clinics are located in the United States in areas with a high number of active-duty personnel. Approximately 969,000, or 54 percent, of active-duty personnel reside in the areas served by the MTFs with chiropractic clinics. To support the benefit, DOD provides annual allotments from its health care budget. In fiscal year 2004, the allotment increased to $11 million. An additional $203,000 was provided by the MTFs with chiropractic clinics in fiscal year 2004. DOD generally adhered to the priorities specified in its implementation plan in selecting the sites for the 42 clinics and in determining the clinics' staffing levels. DOD has not completed other actions described in the implementation plan. For example, DOD's implementation plan stated that a marketing and promotion program, which would include pamphlets and other materials, would be necessary to make active-duty personnel aware of the benefit. However, DOD did not provide active- duty personnel with such materials as specified in the plan. Instead, DOD relied on each MTF to determine whether and how to promote the benefit. The implementation plan also called for close monitoring of the benefit to determine whether the benefit meets current needs, but DOD officials said that they had not monitored whether the benefit meets current or future demand from active-duty personnel. In commenting on a draft of this report, DOD generally agreed with our findings. DOD noted that oversight of the chiropractic clinics is provided at the service level, which involves frequent communication with TMA regarding medical care, budget, and legislative issues that affect the chiropractic program across the military health system. Background: Military health care is provided by TRICARE, DOD's health provider network. TRICARE covers about 9.1 million beneficiaries, including active-duty and retired members of the armed services and their families. The military health system's primary mission is to maintain the health of 1.8 million military personnel engaged in active duty.[Footnote 5] Costing about $17.8 billion in fiscal year 2004, TRICARE is financed through DOD's Defense Health Program (DHP) budget. The services administer TRICARE through their respective MTFs and other providers. Worldwide, DOD has 238 MTFs. The Surgeon General of each service has authority over the MTFs for that branch of the service. Congress has directed that DOD consider implementing a chiropractic benefit in the military health system since the 1980s. The Department of Defense Authorization Act of 1985 mandated that DOD conduct a demonstration project to evaluate the cost-effectiveness of incorporating chiropractic services for active-duty service members, retirees, and their dependents, as part of the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) benefit, the military health system in place prior to TRICARE.[Footnote 6] In August 1993, DOD prepared a report to Congress on the CHAMPUS Chiropractic Demonstration Project. The report stated that after a 2-year demonstration project conducted in two states, DOD did not favor establishing a permanent benefit because other types of care had higher priority for the DHP's limited funds. In the NDAA 1995, Congress directed the Secretary of Defense to establish another demonstration program at no fewer than 10 sites for 3 years to evaluate the feasibility and advisability of expanding DOD's health system to include the chiropractic benefit.[Footnote 7] The NDAA 1995 also directed the Secretary to convene the OAC to, among other things, submit to Congress a plan for evaluating the program. The Secretary, with assistance from the OAC, was required to produce a final report at the conclusion of the demonstration period. The National Defense Authorization Act for Fiscal Year 1998 directed that the demonstration be increased to include at least three additional clinics in the MTFs that were not already designated to participate in the program, and it also extended the program for 2 more years, to conclude at the end of fiscal year 1999.[Footnote 8] DOD issued its Final Chiropractic Health Care Demonstration Program Report in February 2000. The report concluded that it was feasible to integrate chiropractic care services into DOD's health system because chiropractic services complemented traditional medical care for patients with back pain but that it was not advisable to do so because of the additional costs entailed. The report stated that chiropractic care posed an additional cost because it did not fully offset the costs of traditional, nonchiropractic, medical care. DOD estimated that the anticipated total cost of making chiropractic care available to all TRICARE beneficiaries could reach $70 million annually.[Footnote 9] The report also stated that because of fiscal limitations within the military health system, full implementation of the chiropractic benefit would necessitate reducing or eliminating other existing medical programs. In the NDAA 2001, Congress directed DOD to develop a plan to provide the chiropractic benefit for all active-duty members of the military.[Footnote 10] In August 2001, DOD issued its implementation plan, which served as an operational framework for DOD in implementing its chiropractic benefit. Enclosure I lists selected legislation directed toward establishing and increasing the availability of DOD's chiropractic benefit. DOD Has Made the Chiropractic Benefit Available at 42 MTFs in the United States: To implement its chiropractic benefit, DOD has opened chiropractic clinics in 42 of its 238 MTFs. DOD does not currently plan to open additional clinics, but DOD officials said they continue to assess additional need for the benefit. The benefit is provided for active- duty personnel at the MTFs with chiropractic clinics, all of which are located in the United States. The locations for clinics were selected because they are in areas that have a high number of active-duty personnel. Approximately 969,000, or 54 percent, of active-duty personnel, reside in the areas served by the MTFs with chiropractic clinics. DOD allocated $11 million to the benefit in fiscal year 2004, and an additional $203,000 was provided by the MTFs with chiropractic clinics. DOD generally followed its implementation plan in locating and staffing its chiropractic clinics, but it did not actively promote or closely monitor the benefit as described in the plan. DOD Has Opened Clinics at 42 MTFs and Does Not Plan to Open More: DOD has opened chiropractic clinics for active-duty members of the uniformed services at 42 of DOD's 238 MTFs and does not plan to open additional clinics. The NDAA 2001 mandated that DOD create a plan to fully implement the chiropractic benefit; DOD responded by developing and submitting an implementation plan in August 2001 and began implementing the program in October of that same year. By fiscal year 2003, DOD had opened 31 chiropractic clinics. In a committee report for the National Defense Authorization Act for Fiscal Year 2004, the Senate Committee on Armed Services directed that DOD provide the benefit at no fewer than 45 sites by the end of fiscal year 2004.[Footnote 11] DOD officials said they have fulfilled the requirements of the law and do not have immediate plans to add any additional clinics. They also said they will continue to assess additional need for the benefit. The chiropractic clinics have been opened at the MTFs in the United States with large active-duty populations. As of June 2005, the Army had opened the most chiropractic clinics with 17, the Air Force had opened 14, and the Navy had opened 11. Each of the 42 chiropractic clinics accepts active-duty patients from the other services. Figure 1 shows the locations of the MTFs that have chiropractic clinics.[Footnote 12] Figure 1: Location of DOD's 42 Chiropractic Clinics (August 2005): [See PDF for image] Note: Specific locations are listed in enc. II. [End of figure] Fifty-Four Percent of Active-Duty Personnel Are Served by the MTFs with Chiropractic Clinics: Approximately 969,000, or 54 percent, of active-duty personnel, reside in the areas served by the MTFs with chiropractic clinics. (See table 1.) However, DOD officials said that the chiropractic benefit is available to all active-duty personnel because they can be referred by their primary care manager to a chiropractor located in one of DOD's 42 chiropractic clinics. DOD officials said that personnel residing in remote and overseas locations or in locations that are not near an MTF with a chiropractic clinic can travel, if necessary, to receive the benefit. According to DOD data, 19 percent of active-duty personnel currently reside in remote or overseas areas. DOD defines a remote area as an area in the United States in which an active-duty member resides and works more than 50 miles from an MTF. An additional 28 percent of active-duty personnel reside in areas of the U.S. served by MTFs that do not have chiropractic clinics. Currently, there is no provision for active-duty personnel to receive chiropractic services in the civilian or purchased-care sector. Table 1: Proximity of Active Duty Personnel to Chiropractic Clinics (August 2005): Location of active-duty personnel: Residing in areas served by a chiropractic clinic; Active-duty population: 969,000; Percent of active-duty population: 54%. Location of active-duty personnel: Residing in locations not served by a chiropractic clinic: Living overseas; Active-duty population: 246,000; Percent of active-duty population: 14%. Location of active-duty personnel: Residing in locations not served by a chiropractic clinic: Living in remote areas; Active-duty population: 88,000; Percent of active-duty population: 5%. Location of active-duty personnel: Residing in locations not served by a chiropractic clinic: Living in areas of the United States served by MTFs with no chiropractic clinic; Active-duty population: 497,000; Percent of active-duty population: 28%. Location of active-duty personnel: Residing in locations not served by a chiropractic clinic: Total; Active-duty population: 831,000; Percent of active-duty population: 46%. Location of active-duty personnel: Total; Active-duty population: 1,800,000; Percent of active-duty population: 100%. Sources: TMA and the Offices of the Surgeons General of the Air Force, Army, and Navy, DOD. [End of table] DOD's Allotments for the Benefit Have Increased: Since 2002 the chiropractic benefit has been directly funded from the DHP with an annual allotment for each of the services. DOD's annual allotment to the chiropractic benefit has grown over time to $11 million in fiscal year 2004. Table 2 shows the annual DHP allotments for the chiropractic benefit for fiscal years 2002 through 2004 as well as the number of clinics in operation by each service for the same period. Table 2: Annual DHP Allotments Directly for the Chiropractic Program and Number of Clinics, by Service, Fiscal Years 2002-2004: Dollars in millions. Service: Air Force; Fiscal year 2002: DHP allotment: $1.80; Fiscal year 2002: Number of clinics: 4; Fiscal year 2003: DHP allotment: $1.70; Fiscal year 2003: Number of clinics: 8; Fiscal year 2004: DHP allotment: $2.70; Fiscal year 2004: Number of clinics: 14. Service: Army; Fiscal year 2002: DHP allotment: $2.3; Fiscal year 2002: Number of clinics: 5; Fiscal year 2003: DHP allotment: $4.4; Fiscal year 2003: Number of clinics: 13; Fiscal year 2004: DHP allotment: $4.3; Fiscal year 2004: Number of clinics: 17. Service: Navy; Fiscal year 2002: DHP allotment: $1.8; Fiscal year 2002: Number of clinics: 5; Fiscal year 2003: DHP allotment: $3.6; Fiscal year 2003: Number of clinics: 10; Fiscal year 2004: DHP allotment: $4; Fiscal year 2004: Number of clinics: 11. Total; Fiscal year 2002: DHP allotment: $6.00; Fiscal year 2002: Number of clinics: 14; Fiscal year 2003: DHP allotment: $9.80; Fiscal year 2003: Number of clinics: 31; Fiscal year 2004: DHP allotment: $11; Fiscal year 2004: Number of clinics: 42. Source: DOD. Notes: DHP allotments are in millions of dollars. Totals may not add because of rounding. [End of table] Most MTFs provide additional financial support for their respective chiropractic clinics from their own resources. Twenty-six of the 42 MTFs that have chiropractic clinics have provided additional financial support from funds that the MTFs have received for their general use to cover supplies or incidental items. The amount of funding provided by MTFs for their respective clinics has varied from one MTF to another. Table 3 shows the amount of MTF funds provided for chiropractic clinics, as well as the number of clinics in operation, by service for fiscal years 2002 through 2004. Table 3: MTF Funds Provided for Chiropractic Clinics and Number of Clinics, by Service, Fiscal Years 2002-2004: Service: Air Force; Fiscal year 2002: MTF funds: $10,571; Fiscal year 2002: Number of clinics: 4; Fiscal year 2003: MTF funds: $40,642; Fiscal year 2003: Number of clinics: 8; Fiscal year 2004: MTF funds: $94,932; Fiscal year 2004: Number of clinics: 14. Service: Army; Fiscal year 2002: MTF funds: $25,768; Fiscal year 2002: Number of clinics: 5; Fiscal year 2003: MTF funds: $54,012; Fiscal year 2003: Number of clinics: 13; Fiscal year 2004: MTF funds: $44,222; Fiscal year 2004: Number of clinics: 17. Service: Navy; Fiscal year 2002: MTF funds: $111,317; Fiscal year 2002: Number of clinics: 5; Fiscal year 2003: MTF funds: $60,914; Fiscal year 2003: Number of clinics: 10; Fiscal year 2004: MTF funds: $63,674; Fiscal year 2004: Number of clinics: 11. Total; Fiscal year 2002: MTF funds: $147,656; Fiscal year 2002: Number of clinics: 14; Fiscal year 2003: MTF funds: $155,568; Fiscal year 2003: Number of clinics: 31; Fiscal year 2004: MTF funds: $202,828; Fiscal year 2004: Number of clinics: 42. Sources: Offices of the Surgeons General of the Air Force, Army, and Navy. Note: Funds contributed by MTFs were in addition to the DHP allotments provided to the services. [End of table] DOD Generally Followed Its Implementation Plan in Establishing the Benefit: DOD generally followed its implementation plan in selecting sites and determining staffing levels for the chiropractic clinics that were opened after the conclusion of the demonstration project but did not complete other actions described in the implementation plan. In determining locations for chiropractic clinics, DOD noted in its implementation plan that chiropractic care would continue at the 13 MTFs that had chiropractic clinics established for the demonstration project. For each service, the implementation plan included a list of MTFs considered for receiving chiropractic clinics, prioritized by projected demand on the basis of the size of the active duty population served by the MTFs. Decisions about opening chiropractic clinics at particular MTFs also were based upon criteria reflecting specific aspects of the areas served by the MTFs. DOD officials said that, in addition to the criteria used to develop the lists, other factors that were considered included the (1) proximity of other MTFs offering chiropractic services, (2) availability of space at the MTF, and (3) plans for future construction at the MTF. The implementation plan provided the services with guidance on the order for opening the clinics. However, DOD gave the services discretion in deciding which clinics to open on the basis of all of the factors. The locations of the clinics suggest that DOD generally opened clinics at the MTFs in the order in which they appear on the list in its implementation plan. (See enc. II.) The Army opened clinics at 17 of the first 18 MTFs appearing on the list, the Navy opened clinics at 11 of the first 12, and the Air Force opened clinics at 14 of the first 25. Officials from the Surgeons General's offices said that the lack of available space at an MTF was the most common reason that an MTF on the list would not have received a clinic but said that the services carefully evaluated each site on the list. DOD officials said they also generally followed the criteria stated in the implementation plan for staffing the clinics. According to DOD's implementation plan, staffing levels at each clinic would be based on the number of active-duty personnel and historical MTF workloads. DOD assumed that a single chiropractor with one assistant could treat approximately 1,000 patients and handle 4,200 visits a year from these patients. At the end of fiscal year 2004, DOD had staffed its 42 clinics with 58 chiropractors. Most of the clinics are staffed with a single chiropractor. DOD's chiropractors are civilian contractors. The Army and Air Force use a third-party firm to hire their chiropractic contractors, while the Navy hires its entire chiropractic staff through the Navy Medical Logistics Command. Table 4 shows the number of chiropractors staffed in DOD chiropractic clinics, by service, since fiscal year 2002. Table 4: Number of Chiropractors Staffed in DOD Chiropractic Clinics, by Service, Fiscal Years 2002-2004: Service: Air Force; Fiscal Year 2002: 11; Fiscal Year 2003: 14; Fiscal Year 2004: 18. Service: Army; Fiscal Year 2002: 13; Fiscal Year 2003: 19; Fiscal Year 2004: 21. Service: Navy; Fiscal Year 2002: 9; Fiscal Year 2003: 18; Fiscal Year 2004: 19. Total; Fiscal Year 2002: 33; Fiscal Year 2003: 51; Fiscal Year 2004: 58. Sources: Offices of the Surgeons General of the Air Force, Army, and Navy. [End of table] The implementation plan anticipated that staffing requirements would be recomputed according to demand as the chiropractic program matured and data were collected to evaluate the benefit. However, DOD has not conducted a formal assessment of staffing needs since October 2001, when the benefit was first established. Instead, service representatives said they have staffed clinics on the basis of input from the MTFs about how they are handling their workload and said that they communicate as needed with the MTF officials to assess the status of the chiropractic clinics and solve any staffing issues that might arise. DOD has not completed other actions described in the implementation plan. For example, DOD's implementation plan stated that a marketing and promotional program would be necessary to make personnel aware of the benefit, as well as to inform their physicians, case managers, and commanders about the benefit. Such a program was to include promotional materials such as handouts, posters, generic news items for post or base papers, or other similar materials. However, DOD's promotional activities have been limited. For example, DOD officials said that DOD had not provided materials for promoting the chiropractic benefit to the services but had instead left it to the services to promote the benefit. Service representatives said that they had not produced promotional materials about the chiropractic benefit and did not monitor the MTFs' promotional efforts. The MTF staff we interviewed said that they had not produced materials to promote the chiropractic benefit. We found that only 10 of the 42 MTFs with chiropractic clinics included the chiropractic benefit on their Web site. In addition, although the implementation plan stated that DOD would monitor the program to determine whether the benefit meets current needs and to identify future demand, DOD officials told us that they have not conducted such monitoring. Agency Comments: We requested comments on a draft of this report from DOD. DOD provided written comments that are reprinted in enclosure III. In its comments, DOD generally concurred with our findings, noting that oversight of the chiropractic clinics is provided at the service level, which involves frequent communication with TMA regarding medical care, budget, and legislative issues that affect the chiropractic program across the military health system. We incorporated technical comments provided by DOD as appropriate. We are sending copies of this report to the Secretary of Defense, appropriate congressional committees, and other interested parties. Copies will also be made available to others upon request. In addition, this report is available at no charge on GAO's Web site at http://www.gao.gov. If you or your staff have any questions regarding this report, please contact me at (202) 512-7101 or crossem@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Contributions were made by Tom Conahan, Assistant Director; Martin Gahart; Cathleen Hamann, and Carolina Morgan. Signed by: Marcia Crosse: Director, Health Care: Enclosures - 3: Enclosure I: Selected Laws Pertaining to Development of DOD's Chiropractic Benefit: Law: Department of Defense Authorization Act, 1985, Pub. L. No. 98-525 § 632(b), 98 Stat. 2492, 2543 (1984); Description: Directed the Secretary of Defense to conduct demonstration projects to determine the cost-effectiveness of a chiropractic benefit for CHAMPUS-eligible beneficiaries. Law: National Defense Authorization Act for Fiscal Year 1995, Pub. L. No. 103-337, § 731, 108 Stat. 2663, 2809 (1994); Description: Required that the Secretary of Defense establish a 3-year chiropractic demonstration program at no less than 10 military treatment facilities to evaluate the feasibility and advisability of providing chiropractic care through the medical care facilities of the Armed Forces. Provided for establishment of an Oversight Advisory Committee (OAC) to assist and advise in the development and conduct of the demonstration program. Law: National Defense Authorization Act for Fiscal Year 1998, Pub. L. No. 105-85, § 739(a), (b), 111 Stat. 1629, 1815 (1997); Description: Extended the demonstration program for 2 years through fiscal year 1999. Mandated the expansion of the chiropractic health care demonstration program to at least three additional treatment facilities. Law: Floyd D. Spence National Defense Authorization Act for Fiscal Year 2001, Pub. L. No. 106-398, § 702, 114 Stat. 1654, App. A 1654A-173-174 (2000); Description: Required the development and implementation of a plan to provide a permanent chiropractic care benefit for all active-duty personnel to be phased in over a 5-year period, beginning October 1, 2001. Required that GAO monitor the development and implementation of the chiropractic plan.[A]. Law: National Defense Authorization Act for Fiscal Year 2004, Pub. L. No. 108-136, § 711, 117 Stat. 1392, 1530 (2003); Description: Required the Secretary of Defense to accelerate the implementation of the plan to provide a chiropractic benefit for active- duty personnel, with the goal of completing the implementation of the plan by October 1, 2005, rather than the original deadline of October 1, 2006. Source: GAO. Note: CHAMPUS = Civilian Health and Medical Program of the Uniformed Services. [A] We did not evaluate the development of DOD's implementation plan because of our previous role as a member of the OAC in accordance with NDAA 1995. In our role, we participated in developing DOD's implementation plan by providing the OAC with a member. To maintain compliance with the independence requirements of generally accepted government auditing standards, we are unable to evaluate the development of that same plan. [End of table] Enclosure II: Military Treatment Facilities Considered for Chiropractic Clinics, in Order of Projected Demand, by Service: Air Force: Military treatment facilities as listed in implementation plan: 59th Medical Wing, Lackland Air Force Base (AFB), Tex.[A]; Date opened: September 1998. Military treatment facilities as listed in implementation plan: 11th Medical Group, Bolling AFB, D.C; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 10th Medical Group, U.S. Air Force Academy, Colo; Date opened: October 2002. Military treatment facilities as listed in implementation plan: 1st Medical Group, Langley AFB, Va; Date opened: October 2002. Military treatment facilities as listed in implementation plan: 55th Medical Group, Offutt AFB, Nebr.a; Date opened: October 1995. Military treatment facilities as listed in implementation plan: 375th Medical Group, Scott AFB, Ill.a; Date opened: October 1995. Military treatment facilities as listed in implementation plan: 72nd Medical Group, Tinker AFB, Okla; Date opened: February 2004. Military treatment facilities as listed in implementation plan: 96th Medical Group, Eglin AFB, Fla; Date opened: October 2003. Military treatment facilities as listed in implementation plan: 6th Medical Group, MacDill AFB, Fla; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 74th Medical Group, Wright Patterson AFB, Ohio; Date opened: March 2004. Military treatment facilities as listed in implementation plan: 16th Medical Group, Hurlburt Field AFB, Fla; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 60th Medical Group, Travis AFB, Calif.a; Date opened: October 1995. Military treatment facilities as listed in implementation plan: 99th Medical Group, Nellis AFB, Nev; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 3rd Med Group, Elmendorf AFB, Alaska; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 56th Medical Group, Luke AFB, Ariz; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 42nd Medical Group, Maxwell AFB, Ala; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 355 Medical Group, Davis Monthan AFB, Ariz; Date opened: January 2004. Military treatment facilities as listed in implementation plan: 89th Medical Group, Andrews AFB, Md; Date opened: October 2002. Military treatment facilities as listed in implementation plan: 12th Medical Group, Randolph AFB, Tex; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 78th Medical Group, Robins AFB, Ga; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 305th Medical Group, McGuire AFB, N.J; Date opened: February 2004. Military treatment facilities as listed in implementation plan: 377th Medical Group, Kirtland AFB, N. Mex; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 43rd Medical Group Pope AFB, N.C; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: 81st Medical Group, Keesler AFB, Miss; Date opened: October 2002. Military treatment facilities as listed in implementation plan: 2nd Medical Group, Barksdale AFB, La; Date opened: February 2004. Army: Military treatment facilities as listed in implementation plan: Womack Army Medical Center, Fort Bragg, N.C; Date opened: January 2003. Military treatment facilities as listed in implementation plan: Darnall Army Community Hospital, Fort Hood, Tex; Date opened: October 2002. Military treatment facilities as listed in implementation plan: Martin Army Community Hospital, Fort Benning, Ga.[A]; Date opened: October 1995. Military treatment facilities as listed in implementation plan: Blanchfield Army Community Hospital, Fort Campbell, Ky; Date opened: December 2003. Military treatment facilities as listed in implementation plan: Walter Reed Army Medical Center, D.C.[A]; Date opened: September 1998. Military treatment facilities as listed in implementation plan: Kimbrough Ambulatory Care Center, Fort Meade, Md; Date opened: October 2003. Military treatment facilities as listed in implementation plan: Winn Army Community Hospital, Fort Stewart, Ga; Date opened: May 2003. Military treatment facilities as listed in implementation plan: Madigan Army Medical Center, Fort Lewis,Wash; Date opened: April 2003. Military treatment facilities as listed in implementation plan: Reynolds Army Community Hospital, Fort Sill, Okla.[A]; Date opened: September 1995. Military treatment facilities as listed in implementation plan: Ireland Army Community Hospital, Fort Knox, Ky; Date opened: July 2003. Military treatment facilities as listed in implementation plan: Evans Army Community Hospital, Fort Carson, Colo.[A]; Date opened: September 1995. Military treatment facilities as listed in implementation plan: Tripler Army Medical Center, Fort Shafter, Hawaii; Date opened: May 2003. Military treatment facilities as listed in implementation plan: General Leonard Wood Army Community Hospital, Fort Leonard Wood, Mo; Date opened: October 2003. Military treatment facilities as listed in implementation plan: Moncrief Army Community Hospital, Fort Jackson, S.C.[A]; Date opened: September 1995. Military treatment facilities as listed in implementation plan: Eisenhower Army Medical Center, Fort Gordon, Ga; Date opened: July 2003. Military treatment facilities as listed in implementation plan: William Beaumont Army Medical Center, Fort Bliss, Tex; Date opened: April 2003. Military treatment facilities as listed in implementation plan: Dewitt Army Community Hospital, Fort Belvoir, Va; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: Guthrie Ambulatory Healthcare Clinic, Fort Drum, N.Y; Date opened: January 2004. Navy: Military treatment facilities as listed in implementation plan: Naval Medical Center, Portsmouth, Va; Date opened: January 2003. Military treatment facilities as listed in implementation plan: Naval Medical Center, San Diego, Calif; Date opened: September 2003. Military treatment facilities as listed in implementation plan: Naval Hospital, Camp Pendleton, Calif.[A]; Date opened: October 1995. Military treatment facilities as listed in implementation plan: Naval Hospital, Pensacola, Fla; Date opened: September 2003. Military treatment facilities as listed in implementation plan: National Naval Medical Center, Bethesda, Md.[A]; Date opened: August 1999. Military treatment facilities as listed in implementation plan: Naval Hospital, Camp Lejeune, N.C.[A]; Date opened: September 1995. Military treatment facilities as listed in implementation plan: Naval Hospital, Jacksonville, Fla.[A]; Date opened: September 1995. Military treatment facilities as listed in implementation plan: Naval Hospital, Great Lakes, ll; Date opened: October 2003. Military treatment facilities as listed in implementation plan: Naval Medical Clinic, Pearl Harbor, Hawaii; Date opened: No clinic opened. Military treatment facilities as listed in implementation plan: Naval Hospital, Bremerton, Wash; Date opened: September 2002. Military treatment facilities as listed in implementation plan: Naval Hospital, Cherry Point, N.C; Date opened: January 2003. Military treatment facilities as listed in implementation plan: Naval Hospital, Beaufort, S.C; Date opened: October 2002. Sources: Report on Chiropractic Health Care Implementation Plan (August 2001), and the Offices of the Surgeons General for the Air Force, Army, and Navy. Note: Military treatment facilities are arranged by projected demand based on population served by the Military Treatment Facility, within service. [A] Denotes clinics opened for the demonstration project, from fiscal year 1995 through fiscal 2000. [End of table] Comments from the Department of Defense: THE ASSISTANT SECRETARY OF DEFENSE: HEALTH AFFAIRS: WASHINGTON, D. C. 20301-1200: AUG 12 2005: Ms. Marcia Crosse: Director, Health Care: U.S. Government Accountability Office: 441 G Street, N.W. Washington, DC 20548: Dear Ms. Crosse: This is the Department of Defense (DoD) response to the Government Accountability Office (GAO) draft report, "DEFENSE HEALTH CARE: DoD Has Established a Chiropractic Benefit for Active Duty Personnel," dated July 21, 2005, (GAO Code 290253/GAO-05-890R). Thank you for the opportunity to review the draft report. The report makes no specific recommendations to the Department of Defense. We concur with the draft report, but offer the enclosed comments and suggestions to make it more technically accurate. My points of contact are Ms. Anne Giese (Functional) at (703) 681-0039 and Mr. Gunther Zimmerman (Audit Liaison) at (703) 681-3492. Sincerely, Signed by: William Winkenwerder, Jr., MD: Enclosure: As stated: GAO DRAFT REPORT - DATED July 21, 2005 GAO Code 290253/GAO-05-890R): "DEFENSE HEALTH CARE: DoD Has Established a Chiropractic Benefit for Active Duty Personnel" DEPARTMENT OF DEFENSE COMMENTS: OVERALL COMMENTS: Oversight of the Chiropractic clinics is provided at the Service level. The individual Services collect and analyze metrics for the programs at their military treatment facilities. The Services have the responsibility for monitoring execution of the Chiropractic program at their facilities. The Services review the status of their sites on a regular basis in order to renew contracts with the Chiropractors, justify funding requests, and respond to legislative initiatives. TMA is in frequent communication with the Services regarding medical care, budget and legislative issues that impact the Chiropractic care program across the military health system. Data collected by the Services are most useful during the discussions with TMA on issues that affect the entire military health system. (290253): FOOTNOTES [1] Pub. L. No. 106-398, App. A, § 702, 114 Stat. 1654, 1654A-173-174 (2000). [2] An MTF is a military hospital or clinic on or near a military base. [3] Pub. L. No. 103-337, § 731, 108 Stat. 2663, 2809 (1994) (NDAA 1995). [4] We did not evaluate the development of DOD's implementation plan because of our previous role as a member of the OAC in accordance with NDAA 1995. In our role, we participated in developing DOD's implementation plan by providing the OAC with a member. To maintain compliance with the independence requirements of generally accepted government auditing standards, we are unable to evaluate the development of that same plan. [5] In addition to members of the armed forces, "active-duty personnel" also include members of the Coast Guard, the Commissioned Corps of the National Oceanic and Atmospheric Administration, and the Public Health Service. Members of the Reserves and National Guard are also eligible for care in the military health system when they are in active-duty status for over 30 days. [6] Pub. L. No. 98-525, § 632(b), 98 Stat. 2492, 2543 (1984). [7] Pub. L. No. 103-337, § 731, 108 Stat. 2663, 2809 (1994). [8] Pub. L. No. 105-85, § 739(a), (b), 111 Stat. 1629, 1815 (1997). [9] We did not adjust the $70 million figure to 2005 dollars. The figure is taken from DOD's February 2000 report and is in 2000 dollars. [10] Congress did not direct that DOD's plan include the provision of the benefit to military retirees and dependents. [11] S. Rep. No. 108-46 at 331-332 (2003). [12] On May 13, 2005, DOD made recommendations for base realignments and closures. Thirty-six bases that have MTFs with chiropractic clinics would be affected if these recommendations are implemented; 16 would be realigned and 20 would gain additional staff or functions. DOD defines "realignment" as any action that both reduces and relocates functions and civilian personnel positions. DOD has not determined how this would affect the chiropractic program.