ABREVIATIONS

1. GAO Government Accountability Office
2. DHP Defense Health Program
3. DOD Department Of Defense
4. NDAA National Defense Authorization Act
5. OAC Oversight Advisory Committee
6. MTF Military Treatment Facility
7. TMA TRICARE Management Activity
8. CHAMPUS Civilian Health and Medical Program of the Uniformed Services
9. TRICARE DOD’s health provider network
10. DDAA Department of Defense Authorization Act

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, 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.

The military’s health system’s primary mission is to maintain the health of 1.8 million military personnel engaged in active duty. Costing about $17.8 billion in fiscal year 2004, TRICARE is financed through the DOD’s DHP budget, through TRICARE’s respective MTF’s and other providers. Worldwide, DOD has 238 MTF’s. The Surgeon General of each service has authority over the MTF’s for that branch of the service.

In the early 1980’s, Congress directed that DOD consider implementing a chiropractic benefit in the DHP. The DDAA 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 CHAMPUS benefit, the military health system in place prior to TRICARE. In August 1993, DOD reported 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 chiropractic benefit because other types of care had higher priority for DHP’s limited funds.

In the NDAA of 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 and also directed the Secretary to convene the OAC to, among other things, submit to Congress a plan for evaluating the program. The Secretary, with the assistance from the OAC, was required to produce a final report at the conclusion of the demonstration period. The NDAA of 1998 directed that the demonstration be increased to include at least three additional clinics in the MTF’s that were not already designated to participate in the program, and it also extended the program for 2 additional years to conclude at the end of the fiscal year 1999.

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 it was not advisable to do so because of the additional cost entailed. The report stated that chiropractic care would pose an additional cost because it did not fully offset the cost of traditional, non-chiropractic, medical care. The report also estimated that the anticipated total cost to make Chiropractic care available to all TRICARE beneficiaries could reach $70 million annually. 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 of 2001, Congress directed DOD to develop a plan to provide the chiropractic benefit for all active-duty members of the military. In August 2001, DOD issued its implementation plan, which served as an operational framework for DOD in implementing its chiropractic benefit.

RESULTS IN BRIEF

To implement its chiropractic benefit, DOD has opened chiropractic clinics at 42 of its 238 MTF’s, worldwide, and does not plan to add additional clinics at this time. All of DOD’s 1.8 million active-duty personnel are eligible for the chiropractic benefit. The 42 chiropractic clinics are located in the U.S. in areas with a high number of active-duty personnel. Approximately 969,000, or 54%, of active-duty personnel reside in the areas served by the MTF’s with chiropractic clinics. To support the chiropractic benefit, DOD provided annual allotments from its health care budget. In fiscal year 2004, the allotment increased to $11.2 million.

DOD generally adhered to the priorities specified in its implementation plan in selecting the sites for the 42 clinics and determining the clinic’s 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 chiropractic benefit, as well as to inform the MTF’s physicians, case managers and commanders about the benefit. Also, handouts, posters and generic news items for post or base newspapers were to be printed. DOD did not provide such materials. Instead, DOD relied on each MTF to determine whether and how to promote the chiropractic benefit. When MTF staff was interviewed, they denied producing promotional materials for the chiropractic benefit. Only 10 of the 42 MTF’s with chiropractic benefits included the benefit on their Web site. 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 chiropractic benefit meets current or future demand from active-duty personnel.

The NDAA of 2004 directed the DOD to increase the number of MTF’s providing the chiropractic benefit to 45 sites, but DOD has stated that they have fulfilled the requirements of the law and do not have immediate plans to add additional chiropractic clinics. However, DOD stated that they would continue to assess additional need for the chiropractic benefit.

As of June 2005, the Army had opened the most chiropractic clinics with 17, the
Air Force has opened 14 and the Navy had opened 11 clinics. DOD officials generally followed the criteria stated in the implementation plan for staffing the clinics. Staffing levels at each chiropractic 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 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 chiropractic clinics with 58 DC’s. 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.

OVERALL COMMENTS FROM THE DEPARTMENT OF DEFENSE
BY DR. WILLIAM WINKENWERDER, JR., MD

“Oversight of the chiropractic clinics is provided at the Service Level. The individual Services collect and analyze metrics for the programs at their MTF’s. 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.”