This instruction implements Air Force Policy Directive , Medical Operations. This This rewrite of 59 MDWI includes changes as applicable with the instruction does not apply to the Air National Guard or Air Force Reserve. notified IAW AFI , Human Immunodeficiency Virus Program, or Army .. be in accordance the policies outlined in 59 MDWI and the. Air Force Instruction on MEBs. AFIpdf I know is still referenced in some publications but it was replaced by the MEB chapter.

Air Force Instruction 44-157 Pdf

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service, scholarship programs, and the Air Force Reserve. AFI , Medical Evaluation Boards (MEB) and Continued Military Service. AIR FORCE INSTRUCTION PDF - This instruction implements Air Force Policy Directive,.. addressed in 59 MDWI, Infection Prevention and Control. tion and Classification of Air Force Military Personnel. Process supplements to this instruction as shown in Air Force Instruction (AFI) , Publications and TR: AFI and local medical treatment facility.

No symptoms or objective evidence of ischemia, angina or congestive heart failure. Establishes medical standards and examination indtruction. Incentive and Orientation Flights. Appoints members of the Medical Evaluation Board. Must be compatible with the performance of sustained flying operations in austere environments. Air Force personnel must meet Air Force standards while in joint assignments, or inter-Service exchange tours.

Active tuberculosis, where curative therapy requires 15 or more months. Disqualifying or questionable medical conditions discovered during the periodic medical examination or on the AF form Transfer active cases with copy of PCS orders to the gaining waiver authority within 30 calendar days of assignment.

Document administrative updates on the reverse side of the AF Form Oral tissues supporting the prosthesis must be in good health. This information is not disclosed outside DoD. Conditions above must have MEB processing within 90 calendar days of surgery regardless of the results, unless stated otherwise. Do not delay separation or retirement past scheduled date of separation or retirement to complete a instructikn examination unless medical hold is approved See Chapter 6.

Transfer active cases with copy of PCS orders to the gaining waiver authority within 30 calendar days of insrtuction. Major abnormalities and defects of the genitalia such as change of sex, a history thereof, or complications adhesions, disfiguring scars, etc.

Neuropsychological Evaluation Consists of the following tests, as a minimum,: Validity, within 24 months of taking oath of office. Found temporarily medically unfit.

Separation is involuntary, or is voluntary in lieu of trial by court martial, or retirement in lieu of involuntary administrative separation.

If tests are not completed at MEPS, accomplish forcd the following locations: Hearing loss which precludes safe, effective performance of duty despite use of hearing aid. Members of all components on extended active duty EAD not excluded by other directives. Must be compatible with the performance of sustained flying operations in austere environments.

Medical Holdover: In the Army, deployed active duty soldiers return to their unit in a back up capacity when they are injured or ill. However, mobilized injured or ill Army reservists have no similar unit to return to. Consequently, they may be removed from their mobilization orders and retained on active duty in "medical holdover status" and assigned to a unit, such as a medical retention processing unit.

After their mobilization orders expire, they can elect to continue on active duty through a program such as medical retention processing, which allows them to continue receiving pay and benefits. Between and the Army reports that about 26, reservists entered medical holdover status see appendix II. Unlike most injured active duty soldiers, reservists in medical holdover generally live farther from their families than active duty members because the units at military medical facilities are often far from where their families live.

In certain cases reservists in medical holdover may receive treatment and recuperate at home. As of December , about 35 percent of the reservists in medical holdover were being cared for in the CBHCO program.

For example, reservists must live in communities where they can get appropriate care, and they must also be reliable in keeping medical appointments. Neither DOD nor the services systematically determine the consistency of decision making, which would be a key component of quality assurance.

With regard to timeliness, DOD has issued goals for processing service members' cases but is not collecting available information from the services, and military officials have expressed concerns that the goals may not be realistic. Finally, DOD is not exercising any oversight over training for staff in the disability system, despite being required to do so. During both the MEB and PEB stages of the disability process, a service member's case must be reviewed and approved by several officials with different roles.

When rating the severity of a service member's impairment, all services are required to use a common schedule, VA's Schedule for Rating Disabilities VASRD , in accordance with federal law.

For example, if a service member has x- ray evidence of degenerative arthritis affecting two or more joints, "with occasional incapacitating exacerbations," he or she should receive a rating of 20 percent according to the VASRD. The disability council is composed of key officials from the three disability agencies of the services, the VA, and relevant DOD officials from the health affairs, reserve affairs, and personnel departments.

The council's mission is to monitor the administration of the disability system and, according to DOD officials, the council serves as a forum to discuss issues such as rules changes and increasing coordination among the services. Currently, the disability council is facilitating a review and revision of all DOD regulations pertaining to the disability system.

Military officials view the council as a group that aims to meet quarterly to discuss issues raised by the services. By having these meetings, DOD hopes to bring all of the services "on the same page" when it comes to the disability system.

However, military officials reported that the council has not met quarterly in the past year and generally does not produce formal reports for the DOD chain of command. Furthermore, the disability council is staffed by one person at DOD who has additional responsibilities.

Military officials also regard the appeals process as helping to ensure the consistency of disability evaluation decision making. However, not all service members appeal. In addition, during the appeals process additional evidence may be presented that may result in a different outcome for the same case.

Furthermore, the appeals process is designed to determine whether the correct decision was made, rather than whether consistent decisions were made across comparable cases. Lack of Oversight by DOD and the Services Provides Little Assurance Decisions Are Consistent: Despite this policy guidance and the presence of the disability council, both DOD and the three services lack quality assurance mechanisms to ensure that decisions are consistent. Given that one of the primary goals of the disability system is that disability evaluations take place in a consistent manner, collecting and analyzing the service members' final disability determinations are critical for ensuring that decisions are consistent.

DOD regulations recognize this and require that the agency establish necessary reporting requirements to monitor and assess the performance of the disability system and compliance with relevant DOD regulations.

Yet, DOD does not collect information from the services on the final disability determinations and personal characteristics of service members going through the disability system.

In addition, DOD has not established quality parameters for the services to follow to evaluate the consistency of decision making. As a result, the services generally lack a robust quality assurance process. In our past work on federal disability programs, we have recommended that quality assurance have two components: 1 the use of multivariate regression analysis examining disability decisions along with controlling factors to determine whether the decisions are consistent and 2 an in depth independent review of a statistically valid group of case files to determine what factors may contribute to inconsistencies.

However, the services were unable to provide any evidence that they are conducting statistical reviews - such as multivariate regression analysis - on their data to determine the consistency of decision making for service members with similar characteristics.

Furthermore, while we found that the Army is conducting independent reviews of 25 to 30 percent of its PEB cases, the Navy and Air Force conduct these reviews only when a service member appeals the PEB's decision. Additionally, these reviews reflect how a single case's medical evidence supports the dispositions made accuracy rather than the degree to which decisions in cases, in general, with similar impairments and characteristics compare consistency.

Without such an analysis the services are unable to assure that adjudicators are making consistent decisions in reservist and active duty cases with similar characteristics. Officials from the services said that it was very difficult to examine outcomes for consistency because each disability decision is unique and there are a multitude of factors considered when rendering a disability decision, some of which could not be captured in a database.

For example, individuals' pain tolerance varies, along with their motivation to adhere to treatment programs. Nonetheless, other federal disability programs face the same challenges, have acknowledged the importance of determining consistency of decision making, and have taken some initial steps to develop quality assurance systems.

For example, the VA selects a random sample of files for independent review using a standard methodology and compiles the results of these reviews.

The second stage of the process--the PEB--should normally take 40 days or less. Despite establishing these timeliness goals for the services, DOD is not ensuring compliance with them. DOD does not regularly collect available timeliness data from the services, a necessary first step for determining compliance. The services generally are using their databases to track the timeliness of decisions, but military officials cited confusion regarding the start date for the process.

However, we found that the usefulness of these timeliness data may be undermined by confusion among military officials and data entry staff regarding the starting dates for the disability process. We compared original Army PEB case files to Army electronic data from both its MEB and PEB databases, and found that the date a physician dictates a narrative summary, the beginning of the disability process and a critical data point for timeliness calculations, was frequently entered incorrectly into the Army's databases.

When we asked about these errors, Army officials said that increased training of data entry staff would help with these problems. Navy officials also said that there was some confusion about how to record starting dates for cases when additional medical information was needed to make a disability decision for a service member.

Data reported by the services on the timeliness of cases generally show that the services are not meeting DOD timeliness goals see appendix II. Military officials said that these results stemmed in part from the unrealistic nature of the goals themselves. Navy officials told us that they do not consider the day goal as a performance standard for MEB processing to be held accountable for. They said that the day goal is also unrealistic, especially in certain cases when there were addendums to the narrative summary.

Army officials also said that it was unrealistic for all MEB cases to be processed in 30 days because certain cases take longer. For example, cases when a line of duty determination is needed or when certain medical tests are required to diagnose some orthopedic or psychiatric conditions.


The Assistant Secretary of Defense for Health Affairs is given explicit instructions to develop and maintain a training program for MEB and PEB staff, but officials from the Office of Health Affairs indicated they were unaware that they had the responsibility to develop a training program. In addition, despite high turnover among military disability evaluation staff, the services do not have a system to ensure that all staff are properly trained.

This turnover stems, in part, from the military requirement that personnel rotate to different positions in order to be promoted. Depending on the positions involved, military officials told us that some staff remain in their positions from 1 to 6 years, with most remaining about 3 years.

This turnover and the resulting loss of institutional knowledge require that the services systematically track who has been properly trained. However, all of the services lack data systems that would allow them to do so, an issue that was highlighted in a previous report by the RAND Corporation. We also found that reservists may be less likely to receive military disability benefits. Data on years of service and preexisting conditions were not available for this analysis, however, factors that influence disability benefit decisions.

Finally, we were unable to compare processing times for reserve and active duty disability cases because we found that Army data on processing times were not reliable. However, based on these data, some Army officials conclude that reservists' cases often take longer to process through the disability evaluation system than the cases of active duty soldiers. Army Reservists and Active Duty Soldiers in the Disability Evaluation System Had Different Characteristics: From through , the characteristics of Army reservists and active duty soldiers in the disability evaluation system differed in a number of ways.

Specifically, reservists tended to have more impairments than active duty soldiers; they were more likely than active duty soldiers to have three or four impairments. Reservists also experienced higher rates of impairments affecting the cardiovascular and endocrine systems, while active duty soldiers experienced a higher rate of impairments affecting the musculoskeletal system.

Reservists were more often classified in higher pay grades and more often worked as functional support and administration, crafts workers, and service and supply handlers. See appendix IV. Active component soldiers worked more often as infantry and gun crews; electronic equipment repairers; and communications and intelligence specialists.

Shear bond strength of resin cement to an acid etched and a laser irradiated ceramic surface

See figure 3. Eighty percent of reservists were male, compared to 76 percent of active duty soldiers, while, on average, reservists were 11 years older than active duty soldiers. See appendix V. When we controlled for many of the characteristics of reserve and active duty soldiers that could account for their difference in ratings, we found that, among soldiers who received ratings, the ratings assigned to Army reservists were comparable to those assigned to their active duty counterparts.

When we controlled for a more limited number of factors, Army reservists who were determined to be unfit for duty appeared less likely to receive benefits either monthly disability payments or severance pay.

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See appendix I. This analysis of benefit outcomes for Army reserve and active duty disability cases could not account for the influence that preexisting conditions and years of service can have on disability decisions. Specifically, the dates in Army's electronic database often did not correspond with the dates recorded in paper files. Nonetheless, the statistics the Army provided indicate that disability cases reviewed between fiscal years and took consistently longer than those of active duty soldiers.

Over half 54 percent of reserve soldiers took longer than 90 days while over one-third 35 percent of active duty soldiers exceed this threshold. See appendix II for more detail. There are several possible explanations for the differences in processing times between reservists and active duty members, according to the Army.

For example, the Army officials reported that MEBs often must request medical records from private medical practitioners for reservists' cases, which can involve considerable delays. In addition, the personnel documents for reservists are stored in facilities around the U. Due to the lack of data on these issues as well as the problems we encountered with the data provided by the Army we were not able to measure the differences or empirically test possible explanations for differences the Army reported in the timeliness of disability case processing for Army reservists and active duty soldiers.

Conclusions: The military disability system's outcomes can greatly impact the future of service members, including reservists, injured in service to their country. Given the significance of these decisions as well as the latitude that services have to implement the system, it is important that DOD exercise proper oversight to make sure the system meets the needs of service members today and in the future.

However, DOD is not adequately monitoring the outcomes for active duty and reservist cases in the disability evaluation system. DOD and the services do not have complete and reliable data for all aspects of the disability system.

Further, neither DOD nor the services are systematically evaluating consistency and timeliness of decision making in the system. Military officials recognize that in many cases, service members' cases are not determined within timeliness goals and have suggested that the goals may not be appropriate in many cases.

In addition, it may take longer for reservist cases to go through the system. If a goal does not reflect appropriate processing times, it may not be useful as a program management tool. Furthermore, both consistency and timeliness of decisions depend on the adequate training and experience of all participants in the disability system. Yet we found that DOD had little assurance that staff at all levels are properly trained.

Response to Agency Comments: We provided a draft of this report to the Department of Defense for its review. DOD agreed with our recommendations, indicating the Department will implement all of them and listing a number of steps it will take to do so. DOD also provided technical comments, which we incorporated into the report as appropriate. We are sending copies of this report to the Secretary of Defense, relevant congressional committees, and others who are interested.

Copies will also be made available to others upon request. Please contact me on if you or your staff have any questions about this report.

Contact points for our Offices of Congressional Relations and Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix VII. Signed by: Robert E. Robertson: Director Education, Workforce, and Income Security: [End of section] Appendix I: Objective, Scope, and Methodology: The objectives of our report were to determine: 1 how current DOD policies and guidance for disability determinations compare for the Army, Navy, and Air Force, and what policies are specific to reserve component members of the military; 2 what oversight and quality control mechanisms are in place at DOD and these three services of the military to ensure consistent and timely disability rating and benefit decisions for active and reserve component members, and 3 how disability rating and benefit decisions, and processing times compare for active and reserve component members of the Army, the largest branch of the service, and what factors might explain any differences.

In addition, we interviewed officials from military treatment facilities. To determine if outcomes for active duty and reserve service members' disability cases were statistically consistent, we analyzed data provided by the physical evaluation board PEB of the Army. We also obtained summary information on total caseloads and processing times from the services and from the Department of Defense. Based on our assessment of the quality of the Army's data, we concluded that data on disability determinations and ratings made by the Army's PEB were sufficiently reliable for our analysis.

On the other hand, the Army's data on processing times were not reliable for our analysis. We did not test the reliability of statistical data provided by DOD and the services.

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This appendix is organized into two sections: Section 1 describes the analyses related to our tests of data quality and reliability.Military officials said that these results stemmed in part from the unrealistic nature of the goals themselves.

To determine if outcomes for active duty and reserve disability cases were statistically consistent, we analyzed data provided by the Army. These allowed us to compare large groups of active and reserve soldiers, as well as to compare soldiers in specific sets of categories--such as active and reserve soldiers of different grades being evaluated at different PEBs.

Any other neurological condition, regardless of etiology, when after adequate treatment, there remain residuals, such as persistent severe headaches, weakness or paralysis of important muscle groups, deformity, incoordination, pain or sensory disturbance, disturbance of consciousness, speech, or mental defects, or personality changes of such a degree as to definitely interfere with the performance of duty.

Nonetheless, the statistics the Army provided indicate that disability cases reviewed between fiscal years and took consistently longer than those of active duty soldiers.

Currently, the disability council is facilitating a review and revision of all DOD regulations pertaining to the disability system. Additionally, we ran a variety of alternative specifications to ensure the stability and robustness of the results; this included, for example, a model testing the interaction between system affected and occupational specialty[Footnote 26] and a model to account for the clustering and potential "nonindependence" of cases within each PEB.

Specimens in Group 1 were subjected to 9. We did not test the reliability of statistical data provided by DOD and the services. Additionally, soldiers declared fit or separated without benefits do not receive percentage disability ratings, and the Army reports no impairment codes for soldiers declared fit.