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Research Questions

  1. What are key features of the current accession medical screening systems?
  2. What do stakeholders consider to be challenges of these two systems?
  3. What efforts have been considered or made to improve these systems?
  4. What are options for changing the business models of the current systems, and what are potential trade-offs of those options?
  5. What are key considerations for conducting one or more pilot programs to test options for changing the business models of the current systems?

Responsibility for medically screening enlisted and officer applicants for the armed forces falls on two Department of Defense (DoD) organizations: the U.S. Military Entrance Processing Command (USMEPCOM), which screens mainly enlisted applicants at military entrance processing stations (MEPS) throughout the country; and the Department of Defense Medical Examination Review Board (DoDMERB), which contracts with civilian health care providers to screen officer applicants. Given the inconsistencies and inefficiencies of the two systems, the project team was tasked with exploring how best to reform the medical screening process. After conducting interviews, focus groups, and a workshop with key stakeholders; reviewing documentation on current policies and practices; and examining prior DoD efforts at improvement, the team developed three main courses of action (COAs) to reform the business models used for accession medical screening, considered the potential feasibility of implementing each COA, and identified the COA for a hybrid model of the two systems as presenting the least amount of risk while allowing for simultaneous testing of enlisted and officer applicants across the two systems. Because of the potential for major impacts of implementing the hybrid model COA, the team recommended that DoD conduct a pilot program involving a randomized control trial at four experimental sites in the United States. The program incorporates strategic elements of an accession medical screening system (regardless of business model) described by stakeholders, as well as findings from analyses of organizational and geographic-based features using a RAND-developed geographic information system tool.

Key Findings

Stakeholders identified challenges with the current systems:

  • Lack of consistency across MEPS sites and the time required to visit a MEPS for screening are key concerns about the USMEPCOM system.
  • Uncertain quality of reports from civilian providers is a main concern about the DoDMERB system.

Each of the three COAs for reforming the business models of the two systems could have major impacts:

  • A high outsource COA that puts all medical screening under DoDMERB would significantly affect USMEPCOM (as its medical screening function would drop significantly) and DoDMERB (which would need to significantly increase capacity for an influx of enlisted applicants).
  • A low outsource COA that puts all medical screening under USMEPCOM would not have a major impact on USMEPCOM given the size of its current mission, but it would effectively remove DoDMERB from the accession medical mission.
  • The third COA — a hybrid model, in which enlisted and officer applicants can go to DoDMERB or USMEPCOM — would have major impacts on capacity and create new information-sharing requirements.

The third COA is the least risky to adopt:

  • It will not significantly disrupt the organizational structures and staffing of MEPS or DoDMERB.
  • It will allow population cross-flows between systems.
  • It has a template in an existing Marine Corps accession program, although this program may not generalize to other accession sources as it is currently designed.

Recommendations

  • Test the hybrid COA prior to implementation.
  • Use randomized controlled trials at MEPS in four strategic locations (Louisville, Kentucky; Springfield, Massachusetts; San Diego, California; and Cleveland, Ohio).
  • Consider expanding an existing Marine Corps program to other accession sources if the pilot program is too costly.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Overview of Accession Medical Screening Systems, Their Potential Challenges, and Their Relative Advantages and Disadvantages

  • Chapter Three

    Department of Defense and Service Efforts to Improve Accession Medical Screening Processes

  • Chapter Four

    Courses of Action for Business Model Changes to Accession Medical Screening Systems

  • Chapter Five

    Designing Pilot Programs to Assess Course of Action Outcomes

  • Chapter Six

    Conclusions

  • Appendix A

    Focus Group and Interview Methodology

  • Appendix B

    Design Workshop Methodology

  • Appendix C

    Logic Model for Accession Medical Screening System

  • Appendix D

    Theoretical Background of Cluster Analysis

This research was conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute (NDRI), a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

This report is part of the RAND Corporation research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

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