Annual Report of the Surgeon General United States Army Fiscal Year 1958
PATIENT CARE AND RELATED ACTIVITIES
Economy Program
Concerned over the gradually rising costs of patient care in the Army Medical Service, The Surgeon General launched an economy drive in fiscal year 1958 to stop and if possible reverse the trend. He initiated a study, with key individuals of his staff participating, to explore ways and means by which costs could be reduced without lowering the standards of professional care. As a result of this study, he sent a letter to each class II hospital commander, outlining the objectives of the economy program and requesting the commander's personal interest and active cooperation. He emphasized that economies could best be achieved at the local level because commanders have a more intimate knowledge of their conditions than do personnel in the Office of the Surgeon General. He requested that each commander submit a monthly report indicating the progress that was being made in reducing costs, pointing out problems, and offering suggestions. He stressed the fact that he was in no way advocating a reduction in hospital costs by turning away patients and termed as 'false economy' the referral to civilian doctors and hospitals in the Dependents' Care Program of any cases that could be cared for in Army hospitals.
Some of the rise in costs, he stated in his letter, was due to inflation, as reflected in higher salaries and cost of material, to new and costly techniques, and to additional services given to patients, but added that the cost of medical care in Army hospitals was rising at a faster rate than could be explained by these factors. He expressed a conviction that costs could be reduced without decreasing the quality of patient care. Information copies of the letter were sent to surgeons of Army hospitals in CONUS.
By the end of the fiscal year, The Surgeon General was convinced from reports of class II hospital commanders that substantial savings were being achieved and that he was right in his belief that better care could be provided at lower cost through improved efficiencies and economies in hospital management and operation. He hopes the economy program will make it possible to halt the rising medical budget and to channel the savings generated by more efficient operation of hospitals to other essential needs, such as replacement of worn-out and
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obsolete equipment, and so enable the Army Medical Service to accomplish all of its missions more effectively.
Interpersonal Relations
The Surgeon General intensified his efforts during the year to bring about closer personal relationship and better understanding between patients in Army medical treatment facilities and personnel who participate either directly or indirectly in their care and management. He has become increasingly concerned over the fact that while the Army has made steady advances in the science of medicine there is still an urgent need to improve the practice of the art of medicine. He believes that the patient requires strong psychological support; that a close personal bond with his physician is an important factor in his attitude, satisfaction, and recovery; and that the patient should be treated with sympathy, cordiality, and respect by all personnel, administrative as well as professional, who come in contact with him in the inpatient or outpatient services of the hospital or the dispensary. The Surgeon General designated the Professional Division in his office as the action agency to conduct and make more effective the interpersonal relations program.
Replies to a questionnaire sent to dependents of Army, Navy, and Air Force personnel who have used civilian medical facilities under the Dependents' Medical Care Program pointed up the need for improving interpersonal relations in military facilities, particularly in the outpatient service. These dependents were asked, among other questions, why they had chosen a civilian rather than a military treatment facility. Some of their reasons for not selecting the latter were lack of continuity of doctor-patient relationship, long waits, impersonal handling of cases, and crowded conditions. Copies of the replies were distributed to class II Army hospital commanders and all Army surgeons, as a means of stimulating improvements.
Maintenance of personal relationships between individual physicians and individual patients for prolonged periods is difficult in the Army because of constantly changing populations. Increased efforts, however, have been made to establish physician-patient relationships of longer duration. This is particularly helpful, The Surgeon General points out, 'in the case of those who comprise family groups; that is, our married officers and noncommissioned officers. I believe our efforts in this area are already paying dividends.'
Personal continuity is also being emphasized in consultations and referrals. Efforts are to be made when feasible to have the patient always
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see the same doctor. Study is also being given to the problem of how to speed up and regulate the appointment system in order to avoid long waits and overcrowding.
Various other means are being employed to improve personal relations. The emphasis is upon the necessity for diagnosing and treating the whole patient, not just a pathological condition. The program and its problems are discussed at conferences, institutes, and visits of consultants. New personnel are indoctrinated with the importance of the program. Various courses at the Army Medical Service School stress the subject of human relations. A new pamphlet, issued during the fiscal year, requires commanders of all Army medical treatment facilities to conduct annually and 'as often as deemed necessary' a minimum of 4 hours of instruction in interpersonal relations for all nonprofessional personnel. From a series of test television programs, produced at the Walter Reed Army Medical Center late in the fiscal year on the theme of interpersonal relations, it is planned to evolve a suitable 16-mm. sound film in color that can be shown to personnel at Army medical treatment facilities throughout the world.
Professional Consultant Activities
Professional consultants to The Surgeon General continued their efforts to improve standards of patient care and to maintain the health of the Army by monitoring more closely the assignment of key personnel, effecting greater stabilization of tours of duty, preparing publications of a professional and technical nature, making frequent visits to Army medical treatment facilities throughout the world, and developing a close liaison with civilian experts in the various medical and paramedical specialties.
The Professional Division collaborated closely with the Personnel Division in the assignment and utilization of medical and paramedical personnel, particularly those in key professional positions. Shortages of surgical specialists, psychiatrists, and optometrists continue.
Through increased stabilization of tours of duty of medical officers, shortages of specialists were partially alleviated, unit operations were smoother and more effective, and morale was improved.
Medical technical bulletins on amebiasis, tuberculosis, venereal disease, psychiatric treatment and administration, and the use of antibiotics were published. Technical manuals on military psychiatry and Army social work were prepared, as was a standard Army Medical Service Formulary for use in all Army medical treatment facilities.
Increased emphasis has been placed on site visits by professional con-
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sultants in order that they may become better acquainted with the problems of local commands. Consultants visited nearly all of the Army medical treatment facilities in the continental United States and all of such facilities overseas. They gave advice on patient care, personnel requirements, modifications of facilities, and supply problems. They also made suggestions regarding the more effective use of the limited personnel at hand.
Consultants in the Professional Division participated actively in numerous national and international organization meetings.
Close liaison was maintained with American specialty boards and national societies, such as the American College of Physicians and the American College of Surgeons. Consultants in the Professional Division have served as examiners of these specialty boards.
General Medicine
Plans are being made to establish a radioisotope clinic at each of the Army teaching hospitals.
A representative of the Office of the Chief Medical Consultant visited 21 Army medical treatment facilities during the year in order to maintain closer liaison with the medical service in Army hospitals.
Surgery
Medical officers who are certified in many surgical subspecialties and who are chiefs of services at the Walter Reed Army Hospital were assigned additional duties as consultants to The Surgeon General in order to provide advice and guidance in the assignment of surgical subspecialty personnel.
Civilian consultants in each of the surgical subspecialties were also appointed, and a continuing effort was made to utilize to the fullest extent the services of civilian and military consultant groups.
It had been anticipated that in the summer of 1958 deferees available under the Berry Plan would provide relief from the shortage of surgical specialists. The Assistant Secretary of Defense (Health and Medical), however, authorized these deferees to continue training in surgical subspecialties, and this has markedly decreased the number of orthopedic surgeons, neurosurgeons, and general surgeons who will be available for duty this summer. Visits of consultants to various class I Army hospitals throughout CONUS indicate that the numbers of medical officers in the limited MOS (military occupational specialties) categories assigned are insufficient to permit ideal standards of surgery to be practiced. Because of the shortage of personnel, excessive
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backlogs of appointments have been built up in outpatient departments in many hospitals. In order to solve this problem, the Professional Division is cooperating closely with the Personnel Division to supply as well as possible the number of various surgical specialists required to operate Army hospitals.
Consultant visits were made to 44 Army hospitals during the year to determine what problems existed in relation to personnel requirements, the supply of equipment, and required modifications in operating room suites and obstetrical facilities, as well as to assess the reaction of assigned personnel, residents, and interns to the type of duty that they are called upon to perform. Ward rounds were made, and the management of surgical patients was reviewed to evaluate the proficiency of medical officers on the various surgical services. In general, no widespread major irregularities were noted and the surgical care of patients, within the limit of personnel available, was found to be of high standard. Chiefs of surgical services were advised regarding the importance of limiting surgical procedures to the capabilities of the facilities at hand, including surgical competence and support of ancillary teams, such as anesthesia, postoperative wards, and nursing care.
In a 4-week visit to USAREUR (U.S. Army, Europe) in the fall of 1957, the Chief Surgical Consultant found that the Army medical treatment facilities in France and Germany were, by and large, completely adequate, and the professional personnel stationed in USAREUR was sufficient in number to provide a very high standard of medical care.
Surgical residency programs are considered adequate at all class II hospitals except at the William Beaumont Army Hospital, where the lack of clinical material limits the teaching program and makes it impractical at this time to change from a 3- to a 4-year residency.
Psychiatry and Neurology
During the fiscal year, 190 psychiatrists and 16 neurologists were on active duty. Of these, 69 were in the Regular Army, and the vast majority were board eligible in their specialties. Nearly all of the others were Reserve officers on active duty. In addition, 30 Regular Army medical officers were in psychiatry residency training and 8 medical officers in neurology training at Walter Reed and Letterman Army Hospitals. On-the-job training of 6 months' duration was given to volunteer medical officers at Valley Forge, Fitzsimons, and Brooke Army Hospitals. The influx of psychiatrists who have been deferred and received professional training under the Berry Plan is expected to make any further training of this type unnecessary.
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Neuropsychiatric training centers are being established at Fort Bragg, N.C., and at the U.S. Disciplinary Barracks at Fort Leavenworth, Kans., and are expected to be in operation early in fiscal year 1959. An agreement among the Superintendent of St. Elizabeths Hospital, The Surgeon General, and the Provost Marshal General makes it possible to transfer to St. Elizabeths Hospital, Washington, D.C., psychotic general prisoners who require prolonged treatment.
The Surgeon General and the Provost Marshal General have emphasized the value of the Army preventive psychiatric program for disciplinary offenders. This has resulted in a stockade screening program which was placed in operation on almost all posts on CONUS and in most oversea areas. Consideration is being given to the establishment of some type of prestockade screening program whereby a soldier, as soon as he has given indication of being maladjusted or emotionally disturbed, would be seen by the psychiatrist or a member of his staff.
In an effort to insure individual consideration, eliminate oversights, and add impetus to the preventive psychiatric program, the Surgeon General has called attention to the desirability of evaluation by an Army
psychiatrist of all individuals who are being considered for separation from the service because of undesirability and unsuitability, even though such an examination is not a mandatory requirement of current regulations (AR 635-208 and AR 635-209).
Admission rates for psychiatric reasons have been computed yearly from 1938 through 1957. The rate of 9 per 1,000 average strength for calendar year 1957 represents a decrease of almost 20 percent and is the lowest rate yet achieved in the Army. This is considered a reasonably valid index of the effectiveness of the preventive psychiatric program, since the separation of enlisted personnel for undesirability, inaptitude, or unsuitability exhibited a corresponding decrease during 1957, and rates of confinement in disciplinary barracks and stockades also showed a marked decline.
The Judge Advocate General has ruled that overseas commanders do not have authority to hospitalize psychotic nonmilitary patients against their will or forcibly return such individuals to the United States. Considerable thought and effort have been given to the development of an expedient policy to facilitate the proper management of such patients until definitive legislation can be formulated and passed to resolve this most complex problem. Until such legislation is enacted, The Surgeon General is preparing recommendations to overseas commanders, advising them to handle such patients in accordance with
subparagraph 16a(4) of AR 40-212.
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In August 1957, TM 8-244, Military Psychiatry, was published. A technical medical bulletin, Psychiatric Treatment and Administration in Army Hospitals, is in preparation.
Clinical Psychology
The following tabulation lists the clinical psychology officers on duty as of 1 July 1957 and 30 June 1958:
| 1 July 57 | 30 June 58 | |
Clinical psychologists (MOS 2232) | 48 | 38 |
Psychological assistants (MOS 7239) | 7 | 5 |
Officer students at civilian universities | 0 | 2 |
Interns | 0 | 8 |
A total of 16 officer clinical psychologists terminated their military service either through resignations or failure to renew their categories. During the fiscal year, approximately 15 applications were received for the Graduate Psychology Student Program and for commissions by trained psychologists. At least 12 of the latter are expected to be approved. Intern training programs were conducted at Walter Reed and Letterman Army Hospitals.
A clinical psychology exhibit was constructed and shown at the American Psychological Association convention in New York and at the Eastern Psychological Association convention in Philadelphia.
The critical shortage of clinical psychology officers persisted throughout the year. Increased effort has been directed toward procuring more of these specialists.
Social Services
During the fiscal year, 7 social work officers were integrated into the Regular Army and 20 were accepted for category indefinite, bringing the permanent number of such officers on active duty to 84 percent of the 104 authorized. Procurement of these officers has fallen short of authorized strength by an average of 15 to 17 during the past year. Five Regular Army social work officers were enrolled in civilian graduate training for doctoral degrees; two completed this training in June 1958.
When a social work officer was approved for inclusion in the TOE (table of organization and equipment) of the reorganized combat division (pentomic) in January 1957, Maj. Gen. James O. Gillespie, then chief of the Professional Division, termed this 'a significant advance in military medical practice.' In July 1957, the first such officer was assigned to fill a requisition from the 1st Infantry Division. Six combat divisions now have a social work officer as well as six enlisted psychiatric personnel assigned to their clearing company. The clearing
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company now provides the division psychiatrist with the necessary personnel to conduct both a preventive and a treatment psychiatric program.
Pathology and Laboratory Activities
Twenty-nine pathology residents are in training in the five large Army teaching hospitals. In addition, William Beaumont and Madigan Army Hospitals were authorized to conduct resident training in pathology. Civilian training for allied science officers is progressing satisfactorily. Six officers are in training for the doctoral degree in various laboratory reserve specialties. Only four additional officers were selected for civilian training during the coming fiscal year because of a reduction of man-year spaces. The procurement of trained MSC laboratory science officers to meet staffing requirements has been satisfactory, but few officers on Reserve duty who have Ph. D. degrees elect to apply for Regular Army commission or remain on active duty at the conclusion of their obligated service.
Two laboratory courses for enlisted medical technicians are being continued at Brooke Army Medical Center. In October 1957, 25 MSC officers attended a course entitled 'Current Trends in Laboratory Activities,' at the Walter Reed Army Medical Center. The course entitled 'Military Medicine and Allied Science,' for Medical Corps officers was again offered.
Army medical laboratory performance is recorded as prescribed in the new AR 40-24, effective 18 October 1957.
The branch of the Sixth U. S. Army Medical Laboratory at Fort Lewis, Wash., was closed 1 November 1957. The workload was absorbed by the Madigan Army Hospital and the Sixth U. S. Army Medical Laboratory, Fort Baker, Calif.
Food Service
Food service representatives of the Army Medical Service began work in 1955 on a project to develop doctrine for dietary practices in military hospitals that would be in keeping with the advances made in the field of therapeutic nutrition. When they completed their task in the fall of 1957, after more than 2 years of work, the results were approved and adopted by both the Army and Air Force Medical Services. This culminated in the publication, in December 1957, of a joint technical manual (DA TM 8-500/AFM 160-8) entitled 'Hospital Diets.' The manual serves as a guide for the planning, ordering, and preparing of diets in Army and Air Force hospitals. It provides
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information required for the preparation of both regular and modified diets. In addition, it contains data concerning food values, equivalents, and percentages required in the preparation of all diets. The information contained in the manual is designed to meet the increased nutritional requirements of patients suffering from disease and injury and to promote rapid convalescence.
Accreditation of Army Hospitals
The Surgeon General continued to stress the importance of getting every Army hospital accredited by the Joint Commission on Accreditation of Hospitals at the earliest possible date after the hospital has met the requirements for accreditation. Because of the high standards involved, accreditation is considered an extremely useful means for improving hospital care. Since the accreditation program was initiated in 1952, every Army hospital which has requested a survey with a view toward accreditation has achieved its goal. This includes six in oversea areas. Virtually all Army hospitals in the United States with more than 100 beds have been fully accredited. Some of the smaller ones have also been accredited. Others have not yet applied for accreditation.
Army Aeromedical Evacuation
Revisions of doctrine pertaining to Army aeromedical evacuation was prepared in the Office of the Surgeon General and published as change 5 to Field Manual 100-1, Field Service Regulations-Doctrinal Guidance. A formal combat development study, Army Aeromedical Evacuation (classified), was also prepared, approved by coordinating agencies, and distributed throughout the Army.
Armed Services Medical Regulating Activities
During fiscal year 1958, ASMRO (Armed Services Medical Regulating Office) authorized the movement of 22,737 patients, of whom 8,105 were active duty Army personnel. Virtually all patients were moved by air. The total movement included 9,280 oversea patients from debarkation medical facilities to CONUS Armed Forces hospitals, 11,487 patients between CONUS Armed Forces hospitals, and 1,880 active-duty military patients from CONUS Armed Forces hospitals to VA (Veterans' Administration) hospitals. These figures represent decreases from fiscal year 1957 totals as follows: 151 oversea patients, 350 patients transferred between Armed Forces hospitals, and 364 patients
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moved from Armed Forces hospitals to VA hospitals. Table 1 shows how the movement of Army patients compared with those of the other services.
TABLE 1 - Movement of patients authorized by Armed Services Medical Regulating Office
Service | From debarkation hospitals | Between ZI hospitals | To VA hospitals | Total |
Army | 3,774 | 3,653 | 678 | 8,105 |
Navy | 2,428 | 1,965 | 595 | 4,988 |
Air Force | 1,950 | 5,852 | 607 | 8,409 |
Others1 | 1,218 | 17 | 0 | 1,235 |
| Total | 9,280 | 11,487 | 1,880 | 22,737 |
1Includes civilians, merchant marines, and foreign nationals.
In addition, the movement of 5,685 CONUS military patients was authorized by commanders of U. S. armies, commandants of U. S. naval districts, and commanders of U. S. Air Force hospitals without reference to ASMRO. These included 3,495 Army patients, 826 Navy patients, and 1,364 Air Force patients.
Between February and June 1958, ASMRO tested a proposal by Headquarters, U. S. Army, Pacific, that ASMRO notify the command, in advance of debarkation, of the hospital destination in CONUS of
patients requiring special handling or the use of special equipment and possible treatment while en route, as well as those whose family situations require advance knowledge of the patient's final destination. With the concurrence of the Surgeons General of the Army, Navy, and Air Force, a test involving patients in this category enplaning from Tripler Army Hospital, T. H., was conducted. ASMRO officials termed the test successful and stated they would recommend that medical regulating directives be modified to include this procedure.
Utilization of Hospitals and Dispensaries
The hospitalization ratio for active-duty Army personnel increased only slightly in fiscal year 1958 despite the high rates of admissions for Asian influenza and other acute upper respiratory infections.
During the year, the number of beds operating decreased only slightly, from 22,174 on 30 June 1957 to 21,308 at the end of fiscal year 1958. Three hospitals in the continental United States were closed. One of these was a class II installation, Murphy Army Hospital, Waltham, Mass., which was discontinued on 1 January 1958. The other two were the U. S. Army hospitals at Fort Detrick, Md. (July 1957), and Fort Crowder, Mo. (January 1958). Table 2 displays data on operating
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beds, patient census, admissions, and bed occupancy for U. S. Army fixed hospitals, providing information for each of the class II hospitals and for other hospitals, and totals for army areas.
The downward trend in the number of dependents of military personnel occupying beds in Army medical treatment facilities in continental United States was halted at least temporarily during the last half of fiscal year 1958. Following the implementation of the Dependents' Medical Care Act of 1956, which authorized the treatment of dependents in civilian facilities, the daily average of dependents occupying beds in Army hospitals in CONUS declined almost steadily from 2,774 in February 1957 to a low of 2,111 in January 1958. In February 1958, however, the trend was reversed and the daily average rose to 2,417. Despite the low figure for January, the daily average for the last 6 months of the fiscal year was 2,300 as compared to 2,561 during the same period for fiscal year 1957-the first full 6-month period that the Dependents' Medical Care Program was in operation.
Most of the decline in the number of beds occupied by dependents in Army medical treatment facilities in CONUS was due to the decrease in OB-GYN (obstetrical-gynecological) patients. The daily average of beds occupied in Army hospitals by these OB-GYN dependents was only 700 in fiscal year 1958 as compared to 868 in the last 6 months of fiscal year 1957. This represents a decrease of about 30 percent.
Table 3 provides information concerning outpatient care provided to the various categories of personnel by Army hospitals and dispensaries during fiscal year 1958. While the number of outpatient visits of active-duty military personnel declined slightly during the fiscal year, there was an increase in the number of outpatient visits of dependents of military personnel. The largest increase in fiscal year 1958, as compared with fiscal year 1957, was for personnel of the U. S. Public Health Service, Coast Guard, and Coast and Geodetic Survey, and for their dependents.
Dependents' Medical Care Program
Although the consensus is that Medicare (Dependents' Medical Care Program) has achieved its objective of providing medical care to dependents of uniformed services personnel who could not be accommodated in medical service facilities, the cost of operating the program has been higher than had been contemplated, and there was strong indication at the end of the fiscal year that Congress would drastically
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reduce the budget for fiscal year 1959. Congress appropriated $75,000,000 for the fiscal year 1958 program. The original budget for fiscal year 1959 was $71,906,000, but the Appropriations Committee of the House of Representatives reduced it by $10,246,000 and recommended that more extensive use be made of existing military medical facilities.
In an effort to get these funds restored, the Secretary of Defense testified before the House Appropriations Committee in June 1958 that the cost of the program in fiscal year 1959 would probably be closer to $90,000,000 than the $71,906,000 contemplated when the budget was developed. He pointed out that lack of adequate experience in operating the new program had made it impossible to estimate the costs accurately. While he agreed with the committee's statement that better utilization should be made of existing military medical facilities and personnel, he expressed doubt that the program could be administered
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effectively with the legal limitation that the committee proposed. Final action on the budget was still pending at the end of the fiscal year.
In its first annual report, dated 1 June 1958, the Office for Dependents' Medical Care stated that there had been a drop in admissions of dependents to military medical facilities ranging from 5.5 percent for the Army to 21.4 percent for the Navy, while the average daily dependent load in Air Force facilities showed a decline of 17.5 percent. These losses were attributed in large measure to declines in maternity cases, with decreases ranging from 28 to 38 percent. It was principally because of maternity cases that military medical service facilities were overcrowded before the Medicare program. The hospital stay of young mothers was too short in many places. Frequent moves to other sections of the hospitals were often necessary to make beds available for expectant mothers. Now, the report goes on to say, those cared for in uniformed services facilities may be allowed to remain from 5 to 7 days.
Since the inception of the Medicare program on 7 December 1956, there has been strict adherence to three 'free choice' principles: (1) Right of the patient to choose between medical care in uniformed services or civilian facilities, (2) the right of hospitals and physicians to choose not to accept patients under the plan, and (3) the right of the patient to choose the civilian physician desired.
Any limitation on these free-choice principles could have serious repercussions. For example, a restriction on free choice would require dependents in restricted areas to apply and receive special authority for civilian care and, if not administered wisely, could conceivably cause an extremely adverse morale reaction among troops. Conceivably, too, expectant mothers could 'beat the restriction' by presenting themselves to civilian physicians, at time of delivery, as emergency cases. This practice could limit the prenatal care and result in undesirable medical results. Restrictions would also open up a whole new field for fraudulent practices if false statements were made as to residence and status ofthe sponsor.
Dependents receiving care under the program consist largely of young mothers and their children. The first annual Medicare report states that 97.7 percent of all patients were under 40 years of age and that 25 percent were children under 14 (newborn infants are not counted, since it was their mothers who were the patients). Described in broad categories, about 45.6 percent of the patients are maternity cases. Another 28.1 percent are cases involving surgical care, ranging from minor operations requiring hospitalization for only 1 day to the most complex procedures known to surgery, such as neurosurgical procedures and open-heart surgery. The other 26.3 percent consists of patients with
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infections of the respiratory tract, pneumonia, gastroenteritis, and a wide range of ills that are treated medically rather than surgically.
The greatest difficulty in administering the program has been encountered in the authorization of the treatment of patients with conditions in the chronic disease, elective surgery, and psychiatric fields. Medicare officials are giving some consideration to making a request for a legislative change to make possible better administration in this regard but are waiting until they accumulate more experience before making any recommendations.
The Surgeon General, in a memorandum to the Executive Director of Medicare on 4 March 1958, stated that the loss of dependent dental care in most areas of the United States has generated many letters from service personnel who bitterly complain of the loss of still another fringe benefit which they were led to believe, at the time of entrance into the service, would be provided. Pointing out that the purpose of the Medicare Act was 'to create and maintain high morale throughout the uniformed services by providing an improved and uniform program of medical care for members of the uniformed services and their dependents,' he declared that the loss of dependent dental care 'can hardly be construed as contributing to an improved morale program.' He pointed out further that the program has not been 'uniform,' as dependents located in oversea areas are authorized dental care while dependents located in the United States are denied such care in most instances by virtue of the assignment of their sponsors. Even within the United States, he added, uniformity is destroyed since the act authorizes dental care at certain areas considered to be 'remote.'
The problem of providing dental care to dependents of Army personnel has been somewhat alleviated since the close of fiscal year 1957 by the declaration of certain posts, camps, and stations to be 'remote' under the provisions of the law. Before 7 December 1956, the effective date of the Medicare Act, dependents received approximately 16 percent of all dental procedures furnished by the Army Dental Corps in CONUS. By the end of fiscal year 1957, 7 months after the Medicare program began operations, only 2.9 percent of the total dental procedures completed in CONUS was for dependent personnel. At that time, only two Army installations had been declared 'remote' by the Assistant Secretary of Defense (Health and Medical). During fiscal year 1958, additional Army installations requested that they be considered 'remote' under the provisions of AR 40-121. By the end of the fiscal year, 39 such requests had been approved, and the stations involved resumed dependent dental care.
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Air Force dependents have been the greatest users of the Medicare program and have accounted for 39.6 percent of the cost. Navy dependents have accounted for 30.8 percent of the cost; Army dependents, 27.6 percent; and Public Health Service dependents, about 2 percent.
The program has grown rapidly, and the number of beneficiaries is now approaching a quarter of a million. This indicates widespread acceptance of the program, but only by inference can this be interpreted as meaning that the program meets the needs of dependents as they conceive them to be and that the program has won their approval. In an effort to determine the opinions of beneficiaries regarding the program, a simple questionnaire has been mailed each month to 150 sponsors whose dependents have received care. Although this sample is small, it is statistically controlled with great care to insure that it includes a fairly representative cross section of all beneficiaries. Of the sponsors who have returned the questionnaires, 98.7 percent indicated that they were generally satisfied with the care received. Tabulated below are the reasons given for choosing civilian facilities:
Percent | |
| Reside too far from a military facility | 43. 6 |
Type of care required was not available at the military facility | 14. 9 |
Preferred civilian facilities for various reasons | 13. 8 |
| Military facilities were inadequate or overcrowded | 12. 8 |
Although the program appears to be accepted generally by physicians, hospitals, and dependents, it is not universally popular since several of the State medical associations do not agree with the plan. Scheduled allowances of maximum fees are a source of discontent on the part of a considerable number of physicians. To these physicians, the program is a 'third party' that in effect tends to destroy the traditional doctor-patient relationships. The 'free choice' of patients to select their own civilian physician has been a dominant factor in the acceptance of the program by physicians.
Studies conducted during the first year of the program indicated that about 55 percent of the physicians participating had no more than two Medicare cases. Such a small volume explains why many physicians do not keep abreast of all regulations concerning the program.
As a safeguard against abuses, the Department of Defense issued an identification card, Uniformed Services Identification and Privilege Card (DD Form 1173), for use by all eligible dependents 10 years of age and over. As of 1 January 1958, the card became the basis for identification for all dependents seeking medical care.
For the program as a whole, the average length of patient stay in a civilian facility has been 5.4 days, and the average cost to the Govern-
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ment per patient day has been $21.55. This cost appears to be in line with similar costs throughout the Nation.
Between 1 July 1957 and 27 June 1958, the Office for Dependents' Medical Care processed 549,452 claims from physicians, amounting to $41,363,318.86, and 332,742 claims from hospitals, totaling $37,731,621.93. The average cost per claim was $75.28 for physicians and $113.40 for hospitals. Tables 4 and 5 show how these claims were distributed among the four uniformed services.
Branch of service | Claims | Physicians' cost | Percent of cost | |
Number | Percent | |||
Army | 142,373 | 25.9 | $10,873,665,01 | 26.3 |
Navy | 173,822 | 31.8 | $13,091,870.37 | 31.6 |
Air Force | 221,719 | 40.4 | $16,583,351.41 | 40.1 |
PHS | 10,538 | 1.9 | $814,432.07 | 2.0 |
| Total | 549,452 | 100.0 | $41,363,318.86 | 100.0 |
Branch of service | Claims | Hospital cost | Percent of cost | |
Number | Percent | |||
Army | 91,067 | 27.4 | $10,351,670.40 | 27.4 |
Navy | 103,045 | 31.0 | $11,890,788.79 | 31.5 |
Air Force | 132,031 | 39.7 | $14,736,273.87 | 39.1 |
PHS | 6,599 | 1.9 | $752,888.87 | 2.0 |
| Total | 332,742 | 100.0 | $37,731,621.93 | 100.0 |
The claims and costs shown in tables 4 and 5 do not represent all authorized service provided during the period, because claims were still being received for services performed. The administrative cost for processing claims was $1,171,159.79 for physicians and $645,670.52 for hospitals.
As of 31 May 1958, major commanders in the Zone of Interior had processed 754 claims from physicians and hospitals, in the amount of $64,179.84.
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In July 1957, the Inspector General, OTSG (Office of the Surgeon General), inaugurated a program of continuing inspection of all of the approximately 150 contractors and subcontractors in CONUS concerned with the processing of Medicare claims submitted by civilian physicians and hospitals. Initially, inspections were made of civilian agencies located near class II medical installations and activities, concurrently with the annual general inspections of these facilities. During the second half of the year, this program was greatly expanded. Inspection activities were progressively increased and, by the end of the year, 76 agencies representing about 50 percent of the total had been visited. Considering the newness of the Medicare program and the impact it has had on a large segment of the U.S. population, the execution of the program was termed outstanding.
Army Health Experience and Trends
Certain indexes to morbidity among Army troops in fiscal year 1958 reflect the impact of the epidemic of Asian influenza in the early months of the fiscal year and the fact that rates of incidence of upper respiratory infections continued at relatively high levels through the remainder of the year. Admission rates were quite high, as compared with rates in the 2 preceding years. The noneffective rate was affected to a lesser extent, since the influenza and related respiratory conditions seen during the year tended to be uncomplicated and of brief duration. Outpatient visit rates also increased, from 17.5 per 1,000 Army strength per day in 1957 to 18.2 per 1,000 in 1958. Death rates were affected very slightly, if at all.
Admissions.-The admission rate to hospital, dispensary, and quarters for all causes (table 6) increased by 46 percent, responding to a sharp rise in admissions for diseases. Rates in oversea areas continued somewhat higher than those in the United States.
As may be seen in table 7, disease admissions reached a peak rate in October 1957, both in the United States and overseas. Until June, monthly rates for 1958 were much higher than those reported in the corresponding months of 1956 and 1957.
Noneffectiveness.-Increased admission rates being due to conditions of short duration, the average daily noneffective rate did not increase proportionately as the result. Noneffective rates for all causes, diseases, and injuries in fiscal year 1958 and the 2 preceding years are shown in table 8.
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Main building, Brooke Army Hospital, Brooke Army Medical Center, Fort Sam Houston, Tex.
24
[Rates expressed as admissions per 1,000 average strength per year]
| Area | All causes | Disease | Injury | ||||||
1958 | 1957 | 1956 | 1958 | 1957 | 1956 | 1958 | 1957 | 1956 | |
Total Army | 478 | 327 | 339 | 430 | 282 | 291 | 48 | 45 | 48 |
Total United States | 467 | 331 | 326 | 423 | 289 | 281 | 44 | 42 | 45 |
Total overseas | 494 | 323 | 356 | 442 | 273 | 304 | 52 | 50 | 52 |
| Europe | 502 | 327 | 387 | 445 | 269 | 326 | 57 | 58 | 61 |
| Japan-Korea-Ryukyus | 515 | 385 | 344 | 468 | 343 | 304 | 47 | 42 | 40 |
Source: Morbidity Report, DD Form 442 (RCS MED-78).
TABLE 7.-Disease admission rates to hospital, dispensary, and quarters, U. S. Army active-duty personnel by month, fiscal years 1956, 1957, and 1958
[Rates expressed as admissions per 1,000 average strength per year]
Period | Total Army | Total United States | Total overseas | ||||||
1958 | 1957 | 1956 | 1958 | 1957 | 1956 | 1958 | 1957 | 1956 | |
12-month period | 430 | 282 | 291 | 423 | 289 | 281 | 442 | 273 | 304 |
| July | 318 | 241 | 252 | 255 | 226 | 240 | 413 | 262 | 267 |
| August | 306 | 247 | 270 | 261 | 233 | 252 | 375 | 268 | 294 |
| September | 512 | 242 | 268 | 408 | 231 | 249 | 669 | 259 | 291 |
| October | 794 | 252 | 284 | 832 | 244 | 265 | 737 | 263 | 310 |
| November | 483 | 251 | 271 | 492 | 247 | 247 | 469 | 257 | 306 |
| December | 365 | 239 | 249 | 372 | 228 | 217 | 355 | 255 | 296 |
| January | 403 | 306 | 323 | 400 | 307 | 320 | 407 | 306 | 326 |
| February | 489 | 397 | 369 | 542 | 463 | 380 | 412 | 298 | 355 |
| March | 459 | 373 | 358 | 493 | 434 | 354 | 407 | 282 | 364 |
| April | 360 | 316 | 313 | 375 | 350 | 318 | 337 | 264 | 307 |
| May | 298 | 268 | 276 | 294 | 275 | 286 | 307 | 258 | 263 |
| June | 253 | 267 | 252 | 257 | 244 | 242 | 268 | 301 | 266 |
Source: Morbidity Report, DD Form 442 (RCS MED-78).
Hospitalization.-The rate of initial admission to hospital in fiscal year 1958 was 257.5 per 1,000 Army active-duty strength, as compared with 203.7 per 1,000 in 1957. However, since many admissions in fiscal year 1958 were for the treatment of Asian influenza and other
25
TABLE 8.-Noneffective rates during fiscal years 1956, 1957, and 1958
Cause of noneffectiveness | 1958 | 1957 | 1956 |
Disease | 11.2 | 10.0 | 10.7 |
Injury | 2.4 | 2.5 | 2.7 |
| All causes | 13.6 | 12.5 | 13.4 |
acute respiratory infections, the increased admission rate produced a small effect on the patient census and on the average daily number of active-duty Army patients occupying beds. Table 9 displays data on admissions, dispositions, patient census, and average daily bed occupancy for active-duty Army patients in terms of absolute numbers. When average daily bed occupancy is related to mean strength, it is seen that 1.03 percent of active-duty Army personnel were occupying hospital beds on the average day in 1958, in contrast to 0.99 percent in fiscal year 1957.
There were 4,827 retirements and separations of hospitalized Army patients in 1958, and 4,743 such retirements and separations in fiscal year 1957. The rate of disability retirement or separation from hospital was 5.2 per 1,000 strength in fiscal year 1958 and 4.7 per 1,000 in fiscal year 1957.
[Figures in parentheses are subtotals]
Element of patient flow | 1958 | 1957 | 1956 |
Patient census, beginning of fiscal year | 10,666 | 11,542 | 13,989 |
Initial admissions | 239,996 | 204,376 | 224,831 |
Final dispositions | 241,914 | 205,252 | 227,278 |
| Returned to duty | (235,096) | (198,517) | (219,325) |
| Disability retirements | (2,586) | (2,431) | (2,902) |
| Disability separations | (2,241) | (2,311) | (2,727) |
| Other final dispositions | (1,994) | (1,993) | (2,324) |
Patient census, end of fiscal year | 8,745 | 10,666 | 11,542 |
Daily average census | 10,969 | 11,327 | 13,273 |
Daily average occupying beds | 9,563 | 9,912 | 11,603 |
Source: Beds and Patients Report, DD Form 443 (RCS MED-79).
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Examination of registrants for military service.-Fiscal year 1958 marked the eighth year in the processing of selective-service registrants for military service under the provisions of the Universal Military Training and Service Act, as amended. There was no change in the law during this year, nor were there any significant changes in the medical or mental standards for determining the acceptability of registrants for military service with respect to the application of medical standards, but a general policy initiated in 1957 continued through fiscal year 1958; namely, that medical examiners were generally instructed to interpret the standards more rigidly.
Furthermore, increased emphasis was placed on indoctrination and training of medical examiners. Army commanders were requested to arrange for close liaison between installation surgeons and medical officers in examining stations, so as to provide maximum professional assistance and guidance. Also, orientation courses were established by the Army for medical officers assigned to the examining stations, in order to attain greater uniformity in the interpretation of the medical standards. The initial courses were given in April 1957; they are to be repeated periodically. In addition, representatives of The Surgeon General have made frequent technical liaison visits to the examining stations. With respect to the mental standards, AFQT (Armed Forces Qualification Tests) 5 and 6 for evaluating the mental ability of examinees were replaced by AFQT 5B and 6B. The testing procedures were modified for the purpose of improving the screening instruments for 'administrative acceptances'; namely, the acceptance of medically qualified registrants who failed the mental test. Applicable regulations were changed to provide that medically qualified examinees who failed the mental test could be 'administratively accepted' if the following conditions were present: (1) The failure was deliberate, and (2) if properly motivated, the examinee could have attained mental test scores in the upper-half of mental group IV or higher. The main object of these changes was to preclude administrative acceptance of those falling within the lower half of mental group IV.
During the fiscal year 1958, over 318,000 preinduction examinations were performed (table 10). The proportion of examinees found acceptable for military service was much lower than in the previous year. This decrease is attributed chiefly to an increase in disqualification rate for medical reasons (19.7 percent in 1958 versus 15.3 percent in 1957, for medical reasons only). The rise in the medical disqualification rate appears to be primarily the result of more rigid interpretation of the medical standards, closer supervision over the examining stations, and improved training of the medical examiners, as discussed above.
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Results of examination | 1958 | 1957 | 1956 | 1955 | ||||
Number | Percent | Number | Percent | Number | Percent | Number | Percent | |
Disqualified: |
|
|
|
|
|
|
|
|
| Administrative reasons1 | 5,501 | 1.7 | 5,077 | 1.2 | 4,006 | 2.2 | 7,712 | 2.4 |
| Failed mental test only | 50,269 | 15.8 | 70,828 | 16.1 | 26,874 | 14.7 | 48,239 | 15.1 |
| Failed mental test and medically disqualified | 10,399 | 3.3 | 11,980 | 2.7 | 4,057 | 2.2 | 9,620 | 3.0 |
| Medically disqualified only | 62,835 | 19.7 | 67,668 | 15.3 | 29,937 | 16.4 | 62,232 | 19.4 |
| Total | 129,004 | 40.5 | 155,553 | 35.3 | 64,874 | 35.5 | 127,803 | 39.9 |
Found acceptable | 189,410 | 59.5 | 285,605 | 64.7 | 117,873 | 64.5 | 192,486 | 60.1 |
| Total examined | 318,414 | 100.0 | 441,158 | 100.0 | 182,747 | 100.0 | 320,289 | 100.0 |
1Refers primarily to individuals disqualified for moral reasons: for example, criminals, individuals previously discharged from the service under conditions other than honorable, etc. It includes also aliens.
SOURCE: Summary of Registrant Examinations for Induction, DA Form 316 (RCS MED-66).
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In response to calls for inductees by the Department of Defense (table 11), 154,000 registrants were forwarded in fiscal year 1958 by the local boards to the examining stations for induction. Of these, 129,000 registrants qualified for military service and were inducted. All but 75 inductees were assigned to the Army. Those assigned to the other Armed Forces (25 to the Navy and 50 to the Air Force) were reservists who failed to fulfill their training obligations in their Reserve components. Such individuals are forwarded by their local boards for immediate induction and, if found qualified, they are assigned to the armed force of which their Reserve component is a part.
TABLE 11.- Total calls for inductees (in thousands) fiscal years 1955 through 1958
Month | 1958 | 1957 | 1956 | 1955 |
July | 13 | 13 | 10 | 23 |
August | 11 | 13 | 10 | 23 |
September | 8 | 14 | 10 | 23 |
October | 7 | 17 | 10 | 23 |
November | 7 | 17 | 20 | 23 |
December | 7 | 17 | 18 | 23 |
January | 10 | 17 | 6 | 23 |
February | 13 | 14 | 6 | 11 |
March | 13 | 14 | 16 | 11 |
April | 13 | 13 | 6 | 8 |
May | 13 | 13 | 12 | 10 |
June | 10 | 13 | 12 | 10 |
| Total | 125 | 175 | 136 | 211 |
Source: Annual Reports of the Director of Selective Service.
