Defense Health Care:

Collaboration and Criteria Needed For Sizing Graduate Medical Education

HEHS-98-121: Published: Apr 29, 1998. Publicly Released: Apr 29, 1998.

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Pursuant to a legislative requirement, GAO reviewed a Navy advisory council's recommendations for restructuring Navy graduate medical education (GME), focusing on: (1) why the Navy did not accept its council's recommendations for Bethesda GME closures and why its other closure attempts did not succeed; (2) whether the other services already have faced or may face similar experiences; and (3) what improvements may be needed if the services are to successfully make and implement their GME sizing decisions.

GAO noted that: (1) in early 1997, the Navy Surgeon General decided to eliminate 162 GME positions to comply with lower projected wartime requirements and with Department of Defense (DOD) restrictions on the ratio of physicians in training to those deployable; (2) a Navy advisory council, lacking specific guidance but responding to the Navy Surgeon General's indications that GME should occur where active duty personnel are concentrated, recommended that such training be dropped at the Bethesda Medical Center; (3) the Navy Surgeon General, however, instead decided to close some of the Navy's Portsmouth Medical Center's programs following a then newly discussed agreement among DOD and the services' surgeons general to concentrate GME in four geographic locations that included Bethesda and San Diego but not Portsmouth; (4) lacking site selection guidance, the council submitted its recommendation to the Surgeon General without taking account of the agreement, which has never been formalized or acted on by the other services; (5) when announced, the Portsmouth closure decision surprised Navy command and medical center officials there, as well as local congressional representatives; (6) publicized arguments ensued that Portsmouth was as advantageous as Bethesda for concentrating GME and that losing Portsmouth's GME would reduce trainee-provided health care to active duty personnel and other beneficiaries and would harm Navy readiness; (7) although it was unsuccessful, the Surgeon General's office tried justifying the decision and later withdrew it for further study; (8) shortly thereafter and for the same ends, the Army Surgeon General's office sought to eliminate the 64 GME positions at the William Beaumont Medical Center in El Paso, Texas, also without site selection guidance and likewise failing to involve those who were affected; (9) while the Air Force also foresees the need for GME program closures, it has not yet attempted to make them; (10) but in the absence of closure policies and criteria and judging from the Navy's and Army's closure attempt experiences, GAO has no reason to believe that the Air Force would be any more successful in bringing about required GME program adjustments; and (11) while not a direct parallel to DOD GME with its readiness dimension, private-sector medical schools and hospitals have been downsizing their GME programs and in doing so have documented success factors that may provide a useful reference for DOD in developing guidance for its future sizing efforts.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: DOD issued an instruction, number 6015.24, dated January 5, 2001, to implement policy, assign responsibilities, and prescribe procedures to close a GME program when such a program is determined to no longer be needed. This instruction directly responds to GAO's recommendations. GAO will prepare an accomplishment report and, when a GME program is closed, will determine cost savings.

    Recommendation: The Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the services' surgeons general to collaboratively develop GME closure policy guidance and implementing criteria and processes covering such matters as key factors in identifying and winnowing potential sites, how to project and mitigate potentially adverse effects on beneficiary health care and readiness, how and when to involve those affected in the services and local areas in the decisionmaking process, how to reach program closure agreement, and how to communicate and implement the resulting decisions.

    Agency Affected: Department of Defense

  2. Status: Closed - Implemented

    Comments: DOD published instruction 6015.24, dated January 5, 2001, which responded to the recommendation.

    Recommendation: The Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the services' surgeons general to collaboratively provide in the guidance for the potential effects of such DOD and service initiatives as TRICARE, with its emphasis on cost control and primary care, that can affect GME decisions.

    Agency Affected: Department of Defense

  3. Status: Closed - Implemented

    Comments: DOD issued instruction 6015.24, dated January 5, 2001, which responded to the recommendation.

    Recommendation: The Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the services' surgeons general to collaboratively develop, obtain agreement on, and publish such policy guidance before any further GME closure decisions are made.

    Agency Affected: Department of Defense

 

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