Chiropractic has long had an association with the military. Over the past decade, Congress approved (and various presidents signed into law) a series of legislative directives dealing with the integration of chiropractic care into the military health care system. Among them was the National Defense Authorization Act for Fiscal Year 2001, which directed the DoD to develop and implement a plan that would make chiropractic benefits available to all active-duty personnel in the U.S. armed forces.
The DoD's plan was developed in consultation with the Chiropractic Health Care Demonstration Project Oversight Advisory Committee (which was established by a similar defense authorization act in 1995, and included several representatives of the chiropractic profession, as well as the GAO). Among the issues the plan addressed were patient eligibility, access to care, location of chiropractic clinics, and projected costs of care. The GAO also was charged with monitoring the development and implementation of the chiropractic health care plan.
In reviewing the implementation of chiropractic benefits as of 2005, the GAO examined several reports, statutes, and laws containing information related to the DoD's plan, along with specific DoD policies, and financial data obtained from military treatment facilities (MTFs) that had established chiropractic clinics. The GAO also interviewed officials from TRICARE Management Activity, the office responsible for ensuring the DoD's health policy is implemented, and officials and chiropractors from several MTFs that have chiropractic clinics.
GOA Findings
Of the 238 MTFs worldwide, the DoD has established chiropractic clinics at 42 facilities in 23 states and the District of Columbia. Of those clinics, 17 are in the Army. Another 14 are in the Air Force, and the Navy maintains the remaining 11. Each of the clinics accepts active-duty patients from the other services.
While DoD officials "continue to assess additional need" for chiropractic services, the GAO letter states that the department does not plan to open any additional clinics at present. This conflicts with a committee report for the National Defense Authorization Act for Fiscal Year 2004, in which the Senate Armed Services Committee directed that the DoD provide chiropractic benefits at "no fewer than 45 sites" by the end of FY 2004.
With regard to the location of chiropractic clinics, 41 of the 42 facilities are situated in the continental United States, and all are in areas with "a high number of active-duty populations." This equates to approximately 969,000, or 54 percent, of all active-duty personnel residing in the areas served by MTFs with chiropractic clinics.
Exactly how the remaining 46 percent of active-duty personnel are able to receive chiropractic services remains in question, however. According to the GAO, approximately 19 percent of active-duty personnel either reside overseas or in "remote" areas which are at least 50 miles from an MTF. An additional 28 percent of active-duty personnel reside in areas served by MTFs that do not have chiropractic clinics. At present, there is no provision for active-duty personnel to receive chiropractic services in the civilian or purchased-care sector.
In addition, the GAO letter states that the DoD "has not completed other actions described in the implementation plan" to Congress. According to the letter, "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." As an example of underpromoting, the GAO reported that "only 10 of the 42 MTFs with chiropractic clinics included the chiropractic benefit on their Web site."
The implementation plan also called for close monitoring of the chiropractic benefit to determine whether the benefit met current needs and to identify future demand for services. According to the letter, "DoD officials said that they had not monitored whether the benefit meets current or future demand from active-duty personnel."
The DoD, in commenting on a draft of the GAO report, "generally agreed" with the office's findings. However, it pointed out that oversight of the chiropractic clinics "is provided at the service level, which involves frequent communication with TMA [TRICARE] regarding medical care, budget, and legislative issues that affect the chiropractic program across the military health system."
While the Department of Defense appears to have turned somewhat of a blind eye to the mandate to provide chiropractic care to all active-duty members of the armed services, there is some good news for the chiropractic profession, in the form of the Chiropractic Advisory Committee. On Oct. 28, 2004, President Bush signed into law House Resolution 4200, re-establishing the committee, which had been dissolved by the DoD in 2003. As in its previous incarnation, the committee will be responsible for evaluating and documenting the progress of the DoD's chiropractic program. It also is charged with preparing and submitting a report on the program to the Secretary of Defense, along with any recommendations regarding the program's continued development and implementation.
The full GAO letter can be viewed at www.gao.gov/new.items/d05890r.pdf.