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Testimony: 

Before the Subcommittee on National Security and Foreign Affairs, 
Committee on Oversight and Government Reform, House of Representatives: 

United States Government Accountability Office: 

GAO: 

For Release on Delivery Expected at 10:00 a.m. EST: 

Monday, March 5, 2007: 

DOD and VA Health Care: 

Challenges Encountered by Injured Servicemembers during Their Recovery 
Process: 

Statement of Cynthia A. Bascetta: 
Director, Health Care: 

GAO-07-589T: 

GAO Highlights: 

Highlights of GAO-07-589T, a testimony before the Subcommittee on 
National Security and Foreign Affairs, Committee on Oversight and 
Government Reform, House of Representatives 

Why GAO Did This Study: 

As of March 1, 2007, over 24,000 servicemembers have been wounded in 
action since the onset of Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF), according to the Department of Defense 
(DOD). GAO work has shown that servicemembers injured in combat face an 
array of significant medical and financial challenges as they begin 
their recovery process in the health care systems of DOD and the 
Department of Veterans Affairs (VA). 

GAO was asked to discuss concerns regarding DOD and VA efforts to 
provide medical care and rehabilitative services for servicemembers who 
have been injured during OEF and OIF. This testimony addresses (1) the 
transition of care for seriously injured servicemembers who are 
transferred between DOD and VA medical facilities, (2) DODís and VAís 
efforts to provide early intervention for rehabilitation for seriously 
injured servicemembers, (3) DODís efforts to screen servicemembers at 
risk for post-traumatic stress disorder (PTSD) and whether VA can meet 
the demand for PTSD services, and (4) the impact of problems related to 
military pay on injured servicemembers and their families. 

This testimony is based on GAO work issued from 2004 through 2006 on 
the conditions facing OEF/OIF servicemembers at the time the audit work 
was completed. 

What GAO Found: 

Despite coordinated efforts, DOD and VA have had problems sharing 
medical records for servicemembers transferred from DOD to VA medical 
facilities. GAO reported in 2006 that two VA facilities lacked real-
time access to electronic medical records at DOD facilities. To obtain 
additional medical information, facilities exchanged information by 
means of a time-consuming process resulting in multiple faxes and phone 
calls. 

In 2005, GAO reported that VA and DOD collaboration is important for 
providing early intervention for rehabilitation. VA has taken steps to 
initiate early intervention efforts, which could facilitate 
servicemembersí return to duty or to a civilian occupation if the 
servicemembers were unable to remain in the military. However, 
according to DOD, VAís outreach process may overlap with DODís process 
for evaluating servicemembers for a possible return to duty. DOD was 
also concerned that VAís efforts may conflict with the militaryís 
retention goals. In this regard, DOD and VA face both a challenge and 
an opportunity to collaborate to provide better outcomes for seriously 
injured servicemembers. 

DOD screens servicemembers for PTSD but, as GAO reported in 2006, it 
cannot ensure that further mental health evaluations occur. DOD health 
care providers review questionnaires, interview servicemembers, and use 
clinical judgment in determining the need for further mental health 
evaluations. However, GAO found that 22 percent of the OEF/OIF 
servicemembers in GAOís review who may have been at risk for developing 
PTSD were referred by DOD health care providers for further 
evaluations. According to DOD officials, not all of the servicemembers 
at risk will need referrals. However, at the time of GAOís review DOD 
had not identified the factors its health care providers used to 
determine which OEF/OIF servicemembers needed referrals. Although 
OEF/OIF servicemembers may obtain mental health evaluations or 
treatment for PTSD through VA, VA may face a challenge in meeting the 
demand for PTSD services. VA officials estimated that follow-up 
appointments for veterans receiving care for PTSD may be delayed up to 
90 days. 

GAOís 2006 testimony pointed out problems related to military pay have 
resulted in debt and other hardships for hundreds of sick and injured 
servicemembers. Some servicemembers were pursued for repayment of 
military debts through no fault of their own. As a result, 
servicemembers have been reported to credit bureaus and private 
collections agencies, been prevented from getting loans, gone months 
without paychecks, and sent into financial crisis. In a 2005 testimony 
GAO reported that poorly defined requirements and processes for 
extending the active duty of injured and ill reserve component 
servicemembers have caused them to be inappropriately dropped from 
active duty, leading to significant gaps in pay and health insurance 
for some servicemembers and their families. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-589T]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Cynthia A. Bascetta at 
(202) 512-7101 or bascettac@gao.gov. 

[End of section] 

Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today to discuss health care and other services 
for U.S. military servicemembers wounded during Operation Enduring 
Freedom (OEF) or Operation Iraqi Freedom (OIF).[Footnote 1] On March 1, 
2007, the Department of Defense (DOD) reported that over 24,000 
servicemembers have been wounded in action since the onset of the two 
conflicts. In 2005, DOD reported that about 65 percent of the OEF and 
OIF servicemembers wounded in action were injured by blasts and 
fragments from improvised explosive devices, land mines, and other 
explosive devices. More recently, DOD estimated in 2006 that as many as 
28 percent of those injured by blasts and fragments have some degree of 
trauma to the brain. These injuries often require comprehensive 
inpatient rehabilitation services to address complex cognitive and 
physical impairments. In addition to their physical injuries, OEF/OIF 
servicemembers who have been injured in combat may also be at risk for 
developing mental health impairments, such as post-traumatic stress 
disorder (PTSD), which research has shown to be strongly associated 
with experiencing intense and prolonged combat.[Footnote 2] 

While servicemembers are on active duty, DOD decides where they receive 
their care--at a military treatment facility (MTF), from a TRICARE 
civilian provider,[Footnote 3] or at a Department of Veterans Affairs 
(VA) medical facility. From the OEF and OIF conflict areas, seriously 
injured servicemembers are usually brought to Landstuhl Regional 
Medical Center in Germany for treatment. From there, they are usually 
transported to MTFs located in the United States, with most of the 
seriously injured admitted to Walter Reed Army Medical Center or the 
National Naval Medical Center, both of which are in the Washington, 
D.C., area.[Footnote 4] Once the servicemembers are medically 
stabilized, DOD can elect to send those with traumatic brain injuries 
and other complex trauma, such as missing limbs, to one of the four 
polytrauma rehabilitation centers (PRC)[Footnote 5] operated by VA for 
medical and rehabilitative care. The PRCs are located at VA medical 
centers in Palo Alto, California; Tampa, Florida; Minneapolis, 
Minnesota; and Richmond, Virginia. While many servicemembers who 
receive such rehabilitative services return to active duty after they 
are treated, others who are more seriously injured are likely to be 
discharged from their military obligations and return to civilian life 
with disabilities. 

Our work has shown that servicemembers injured in combat face an array 
of significant medical and financial challenges as they begin their 
recovery process in the DOD and VA health care systems. In light of 
these challenges and recent media reports that have highlighted 
unsanitary and decrepit living conditions at the Walter Reed Army 
Medical Center,[Footnote 6] you asked us to discuss concerns we have 
identified regarding DOD and VA efforts to provide medical care and 
rehabilitative services for servicemembers who have been injured during 
OEF and OIF. Specifically, my remarks today will focus on (1) the 
transition of care for seriously injured OEF/OIF servicemembers--those 
with traumatic brain injuries or other complex trauma, such as missing 
limbs--who are transferred between DOD and VA medical facilities; (2) 
DOD's and VA's efforts to provide early intervention for rehabilitation 
services as soon as possible after the onset of a disability for 
seriously injured servicemembers; (3) DOD's efforts to screen OEF/OIF 
servicemembers at risk for PTSD and whether VA can meet the demand for 
PTSD services; and (4) the impact of problems related to military pay 
on injured servicemembers and their families. 

My testimony is based on issued GAO work.[Footnote 7] The information I 
am reporting today reflects the conditions facing OEF/OIF 
servicemembers at the time the audit work was completed and illustrates 
the types of problems injured servicemembers encountered during their 
healing and rehabilitation process. To complete the work for these 
products, we visited DOD and VA facilities, reviewed relevant 
documents, analyzed DOD data, and interviewed DOD and VA officials. Our 
work was performed in accordance with generally accepted government 
auditing standards. 

In summary, DOD and VA have made various efforts to provide medical 
care and rehabilitative services for OEF/OIF servicemembers. The 
departments established joint programs to facilitate the transfer of 
injured servicemembers from DOD facilities to VA medical facilities, 
assess whether servicemembers will be able to remain in the military, 
and assign VA social workers to selected MTFs to coordinate the 
transfers. DOD has also established a program to screen servicemembers 
after their deployment outside of the United States has ended to assess 
whether they are at risk for PTSD. However, we found several problems 
in the efforts to provide health care and rehabilitative services for 
OEF/OIF servicemembers. For example, DOD and VA had problems sharing 
medical records and questions arose about the timing of VA's outreach 
to servicemembers whose discharge from military service was not 
certain. Furthermore, we found that DOD cannot provide reasonable 
assurance that OEF/OIF servicemembers who need referrals for mental 
health evaluations receive them. Finally, problems related to military 
pay have resulted in overpayments and debt for hundreds of sick and 
injured servicemembers. 

DOD and VA Have Taken Actions to Facilitate the Transfer of 
Servicemembers but Experienced Problems in Exchanging Health Care 
Information: 

In our June 2006 report, we found that DOD and VA had taken actions to 
facilitate the transition of medical and rehabilitative care for 
seriously injured servicemembers who were being transferred from MTFs 
to PRCs.[Footnote 8] For example, in April 2004, DOD and VA signed a 
memorandum of agreement that established referral procedures for 
transferring injured servicemembers from DOD to VA medical facilities. 
DOD and VA also established joint programs to facilitate the transfer 
to VA medical facilities, including a program that assigned VA social 
workers to selected MTFs to coordinate transfers. 

Despite these coordination efforts, we found that DOD and VA were 
having problems sharing the medical records VA needed to determine 
whether servicemembers' medical conditions allowed participation in 
VA's vigorous rehabilitation activities. DOD and VA reported that as of 
December 2005 two of the four PRCs had real-time access to the 
electronic medical records maintained at Walter Reed Army Medical 
Center and only one of the two also had access to the records at the 
National Naval Medical Center. In cases where medical records could not 
be accessed electronically, the MTF faxed copies of some medical 
information, such as the patient's medical history and progress notes, 
to the PRC. Because this information did not always provide enough data 
for the PRC provider to determine if the servicemember was medically 
stable enough to be admitted to the PRC, VA developed a standardized 
list of the minimum types of health care information needed about each 
servicemember transferring to a PRC. Even with this information, PRC 
providers frequently needed additional information and had to ask for 
it specifically. For example, if the PRC provider notices that the 
servicemember is on a particular antibiotic therapy, the provider may 
request the results of the most recent blood and urine cultures to 
determine if the servicemember is medically stable enough to 
participate in strenuous rehabilitation activities. According to PRC 
officials, obtaining additional medical information in this way, rather 
than electronically, is very time consuming and often requires multiple 
phone calls and faxes. VA officials told us that the transfer could be 
more efficient if PRC medical personnel had real-time access to the 
servicemembers' complete DOD electronic medical records from the 
referring MTFs. However, problems existed even for the two PRCs that 
had been granted electronic access. During a visit to those PRCs in 
April 2006, we found that neither facility could access the records at 
Walter Reed Army Medical Center because of technical difficulties. 

DOD and VA Collaboration Is Important for Early Intervention for 
Rehabilitation: 

As discussed in our January 2005 report, the importance of early 
intervention for returning individuals with disabilities to the 
workforce is well documented in vocational rehabilitation 
literature.[Footnote 9] In 1996, we reported that early intervention 
significantly facilitates the return to work but that challenges exist 
in providing services early.[Footnote 10] For example, determining the 
best time to approach recently injured servicemembers and gauge their 
personal receptivity to considering employment in the civilian sector 
is inherently difficult. The nature of the recovery process is highly 
individualized and requires professional judgment to determine the 
appropriate time to begin vocational rehabilitation. Our 2007 High-Risk 
Series: An Update designates federal disability programs as "high risk" 
because they lack emphasis on the potential for vocational 
rehabilitation to return people to work.[Footnote 11] 

In our January 2005 report, we found that servicemembers whose 
disabilities are definitely or likely to result in military separation 
may not be able to benefit from early intervention because DOD and VA 
could work at cross purposes. In particular, DOD was concerned about 
the timing of VA's outreach to servicemembers whose discharge from 
military service is not yet certain. DOD was concerned that VA's 
efforts may conflict with the military's retention goals. When 
servicemembers are treated as outpatients at a VA or military hospital, 
DOD generally begins to assess whether the servicemember will be able 
to remain in the military. This process can take months. For its part, 
VA took steps to make seriously injured servicemembers a high priority 
for all VA assistance. Noting the importance of early intervention, VA 
instructed its regional offices in 2003 to assign a case manager to 
each seriously injured servicemember who applies for disability 
compensation. VA had detailed staff to MTFs to provide information on 
all veterans' benefits, including vocational rehabilitation, and 
reminded staff that they can initiate evaluation and counseling, and, 
in some cases, authorize training before a servicemember is discharged. 
While VA tries to prepare servicemembers for a transition to civilian 
life, VA's outreach process may overlap with DOD's process for 
evaluating servicemembers for a possible return to duty. 

In our report, we concluded that instead of working at cross purposes 
to DOD goals, VA's early intervention efforts could facilitate 
servicemembers' return to the same or a different military occupation, 
or to a civilian occupation if the servicemembers were not able to 
remain in the military. In this regard, the prospect for early 
intervention with vocational rehabilitation presents both a challenge 
and an opportunity for DOD and VA to collaborate to provide better 
outcomes for seriously injured servicemembers. 

DOD Screens Servicemembers for PTSD after Deployment, but DOD and VA 
Face Challenges Ensuring Further PTSD Services: 

In our May 2006 report, we described DOD's efforts to identify and 
facilitate care for OEF/OIF servicemembers who may be at risk for 
PTSD.[Footnote 12] To identify such servicemembers, DOD uses a 
questionnaire, the DD 2796, to screen OEF/OIF servicemembers after 
their deployment outside of the United States has ended. The DD 2796 is 
used to assess servicemembers' physical and mental health and includes 
four questions to identify those who may be at risk for developing 
PTSD. We reported that according to a clinical practice guideline 
jointly developed by DOD and VA, servicemembers who responded 
positively to at least three of the four PTSD screening questions may 
be at risk for developing PTSD. DOD health care providers review 
completed questionnaires, conduct face-to-face interviews with 
servicemembers, and use their clinical judgment in determining which 
servicemembers need referrals for further mental health 
evaluations.[Footnote 13],[Footnote 14] OEF/OIF servicemembers can 
obtain the mental health evaluations, as well as any necessary 
treatment for PTSD, while they are servicemembers--that is, on active 
duty--or when they transition to veteran status if they are discharged 
or released from active duty. 

Despite DOD's efforts to identify OEF/OIF servicemembers who may need 
referrals for further mental health evaluations, we reported that DOD 
cannot provide reasonable assurance that OEF/OIF servicemembers who 
need the referrals receive them. Using data provided by DOD,[Footnote 
15] we found that 22 percent, or 2,029, of the 9,145 OEF/OIF 
servicemembers in our review who may have been at risk for developing 
PTSD were referred by DOD health care providers for further mental 
health evaluations. Across the military service branches, DOD health 
care providers varied in the frequency with which they issued referrals 
to OEF/OIF servicemembers with three or more positive responses to the 
PTSD screening questions--the Army referred 23 percent, the Air Force 
about 23 percent, the Navy 18 percent, and the Marines about 15 
percent. According to DOD officials, not all of the OEF/OIF 
servicemembers with three or four positive responses on the screening 
questionnaire need referrals. As directed by DOD's guidance for using 
the DD 2796, DOD health care providers are to rely on their clinical 
judgment to decide which of these servicemembers need further mental 
health evaluations. However, at the time of our review DOD had not 
identified the factors its health care providers used to determine 
which OEF/OIF servicemembers needed referrals. Knowing these factors 
could explain the variation in referral rates and allow DOD to provide 
reasonable assurance that such judgments are being exercised 
appropriately.[Footnote 16] We recommended that DOD identify the 
factors that DOD health care providers used in issuing referrals for 
further mental health evaluations to explain provider variation in 
issuing referrals. DOD concurred with the recommendation. 

Although OEF/OIF servicemembers may obtain mental health evaluations or 
treatment for PTSD through VA when they transition to veteran status, 
VA may face a challenge in meeting the demand for PTSD services. In 
September 2004 we reported that VA had intensified its efforts to 
inform new veterans from the Iraq and Afghanistan conflicts about the 
health care services--including treatment for PTSD--VA offers to 
eligible veterans.[Footnote 17] We observed that these efforts, along 
with expanded availability of VA health care services for Reserve and 
National Guard members, could result in an increased percentage of 
veterans from Iraq and Afghanistan seeking PTSD services through VA. 
However, at the time of our review officials at six of seven VA medical 
facilities we visited explained that while they were able to keep up 
with the current number of veterans seeking PTSD services, they may not 
be able to meet an increase in demand for these services. In addition, 
some of the officials expressed concern because facilities had been 
directed by VA to give veterans from the Iraq and Afghanistan conflicts 
priority appointments for health care services, including PTSD 
services. As a result, VA medical facility officials estimated that 
follow-up appointments for veterans receiving care for PTSD could be 
delayed. VA officials estimated the delays to be up to 90 days. 

Problems Related to Military Pay Have Resulted in Debt and Other 
Hardships for Hundreds of Sick and Injured Servicemembers: 

As discussed in our April 2006 testimony, problems related to military 
pay have resulted in overpayments and debt for hundreds of sick and 
injured servicemembers.[Footnote 18] These pay problems resulted in 
significant frustration for the servicemembers and their families. We 
found that hundreds of battle-injured servicemembers were pursued for 
repayment of military debts through no fault of their own, including at 
least 74 servicemembers whose debts had been reported to credit bureaus 
and private collections agencies. In response to our audit, DOD 
officials said collection actions on these servicemembers' debts had 
been suspended until a determination could be made as to whether these 
servicemembers' debts were eligible for relief. 

Debt collection actions created additional hardships on servicemembers 
by preventing them from getting loans to buy houses or automobiles or 
pay off other debt, and sending several servicemembers into financial 
crisis. Some battle-injured servicemembers forfeited their final 
separation pay to cover part of their military debt, and they left the 
service with no funds to cover immediate expenses while facing 
collection actions on their remaining debt. 

We also found that sick and injured servicemembers sometimes went 
months without paychecks because debts caused by overpayments of combat 
pay and other errors were offset against their military pay.[Footnote 
19] Furthermore, the longer it took DOD to stop the overpayments, the 
greater the amount of debt that accumulated for the servicemember and 
the greater the financial impact, since more money would eventually be 
withheld from the servicemember's pay or sought through debt collection 
action after the servicemember had separated from the service. 

In our 2005 testimony about Army National Guard and Reserve 
servicemembers, we found that poorly defined requirements and processes 
for extending injured and ill reserve component servicemembers on 
active duty have caused servicemembers to be inappropriately dropped 
from active duty.[Footnote 20] For some, this has led to significant 
gaps in pay and health insurance, which has created financial hardships 
for these servicemembers and their families. 

Mr. Chairman, this completes my prepared remarks. I would be happy to 
respond to any questions you or other members of the subcommittee may 
have at this time. 

Contacts and Acknowledgments: 

For further information about this testimony, please contact Cynthia A. 
Bascetta at (202) 512-7101 or bascettac@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this statement. Michael T. Blair, Jr., Assistant 
Director; Cynthia Forbes; Krister Friday; Roseanne Price; Cherie' 
Starck; and Timothy Walker made key contributions to this statement. 

[End of section] 

Related GAO Products: 

High-Risk Series: An Update. GAO-07-310. Washington, D.C.: January 
2007. 

VA and DOD Health Care: Efforts to Provide Seamless Transition of Care 
for OEF and OIF Servicemembers and Veterans. GAO-06-794R. Washington, 
D.C.: June 30, 2006. 

Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its 
Providers Use to Make Mental Health Evaluation Referrals for 
Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006. 

Military Pay: Military Debts Present Significant Hardships to Hundreds 
of Sick and Injured GWOT Soldiers. GAO-06-657T. Washington, D.C.: April 
27, 2006. 

Military Disability System: Improved Oversight Needed to Ensure 
Consistent and Timely Outcomes for Reserve and Active Duty Service 
Members. GAO-06-362. Washington, D.C.: March 31, 2006. 

Military Pay: Gaps in Pay and Benefits Create Financial Hardships for 
Injured Army National Guard and Reserve Soldiers. GAO-05-322T. 
Washington, D.C.: February 17, 2005. 

Vocational Rehabilitation: More VA and DOD Collaboration Needed to 
Expedite Services for Seriously Injured Servicemembers. GAO-05-167. 
Washington, D.C.: January 14, 2005. 

VA and Defense Health Care: More Information Needed to Determine If VA 
Can Meet an Increase in Demand for Post-Traumatic Stress Disorder 
Services. GAO-04-1069. Washington, D.C.: September 20, 2004. 

SSA Disability: Return-to-Work Strategies from Other Systems May 
Improve Federal Programs. GAO/HEHS-96-133. Washington, D.C.: July 11, 
1996. 

FOOTNOTES 

[1] OEF, which began in October 2001, supports combat operations in 
Afghanistan and other locations, and OIF, which began in March 2003, 
supports combat operations in Iraq and other locations. 

[2] Charles W. Hoge et al., "Combat Duty in Iraq and Afghanistan, 
Mental Health Problems, and Barriers to Care," The New England Journal 
of Medicine, 351 (2004): 13-22. 

[3] DOD provides health care through TRICARE--a regionally structured 
program that uses civilian contractors to maintain provider networks to 
complement health care services provided at MTFs. 

[4] Other MTFs that received OEF/OIF servicemembers include Brooke Army 
Medical Center (San Antonio, Texas), Dwight David Eisenhower Army 
Medical Center (Augusta, Georgia), Madigan Army Medical Center (Tacoma, 
Washington), Darnall Army Community Hospital (Fort Hood, Texas), Evans 
Army Community Hospital (Fort Carson, Colorado), and the Naval Hospital 
Camp Pendleton (Camp Pendleton, California). 

[5] The Veterans Health Programs Improvement Act of 2004, Pub. L. No. 
108-422, ß 302, 118 Stat. 2379, 2383-86, mandated that VA establish 
centers for research, education, and clinical activities related to 
complex multiple trauma associated with combat injuries. In response to 
that mandate, VA established PRCs at four VA medical facilities with 
expertise in traumatic amputation, spinal cord injury, traumatic brain 
injury, and blind rehabilitation. A PRC addresses the rehabilitation 
needs of the combat injured in one setting and in a coordinated manner. 

[6] See, for instance, Dana Priest and Anne Hull, "Soldiers Face 
Neglect, Frustration at Army's Top Medical Facility," The Washington 
Post (Feb. 18, 2007). 

[7] See Related GAO Products at the end of this statement. 

[8] GAO, VA and DOD Health Care: Efforts to Provide Seamless Transition 
of Care for OEF and OIF Servicemembers and Veterans, GAO-06-794R 
(Washington, D.C.: June 30, 2006). 

[9] GAO, Vocational Rehabilitation: More VA and DOD Collaboration 
Needed to Expedite Services for Seriously Injured Servicemembers, GAO- 
05-167 (Washington, D.C.: Jan. 14, 2005). 

[10] We also reported on early intervention in GAO, SSA Disability: 
Return-to-Work Strategies from Other Systems May Improve Federal 
Programs, GAO/HEHS-96-133 (Washington, D.C.: July 11, 1996). 

[11] GAO, High-Risk Series: An Update, GAO-07-310 (Washington, D.C.: 
January 2007). 

[12] GAO, Post-Traumatic Stress Disorder: DOD Needs to Identify the 
Factors Its Providers Use to Make Mental Health Evaluation Referrals 
for Servicemembers, GAO-06-397 (Washington, D.C.: May 11, 2006). 

[13] Health care providers that review the DD 2796 may include 
physicians, physician assistants, nurse practitioners, or independent 
duty medical technicians--enlisted personnel who receive advanced 
training to provide treatment and administer medications. 

[14] DOD's referrals are used to document DOD's assessment that 
servicemembers are in need of further mental health evaluations. 

[15] In our review we analyzed computerized data provided by DOD to 
identify 178,664 OEF/OIF servicemembers who were deployed in support of 
OEF/OIF from October 1, 2001, through September 30, 2004, and who have 
since been discharged or released from active duty. These 
servicemembers had answered the four PTSD screening questions on the DD 
2796 and had a record of their completed questionnaire available in a 
DOD computerized database. We found that DOD data indicated 9,145 of 
the 178,664 servicemembers in our review may have been at risk for 
developing PTSD. 

[16] The John Warner National Defense Authorization Act for Fiscal Year 
2007 required DOD to develop guidelines for mental health referrals, as 
well as mechanisms to ensure proper training and oversight, by April 
2007. Pub. L. No. 109-364, ß 738, 120 Stat. 2083, 2303-4. 

[17] GAO, VA and Defense Health Care: More Information Needed to 
Determine If VA Can Meet an Increase in Demand for Post-Traumatic 
Stress Disorder Services, GAO-04-1069 (Washington, D.C.: Sept. 20, 
2004). 

[18] GAO, Military Pay: Military Debts Present Significant Hardships to 
Hundreds of Sick and Injured GWOT Soldiers, GAO-06-657T (Washington, 
D.C.: April 27, 2006). 

[19] We found that after voluntary allotments and other required 
deductions, many times there was no net pay due the servicemember. 

[20] GAO, Military Pay: Gaps in Pay and Benefits Create Financial 
Hardships for Injured Army National Guard and Reserve Soldiers, GAO-05- 
322T (Washington, D.C.: Feb. 17, 2005). 

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