Defense Health Care:

Actions Needed to Determine the Required Size and Readiness of Operational Medical and Dental Forces

GAO-19-206: Published: Feb 21, 2019. Publicly Released: Feb 21, 2019.

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Brenda S. Farrell
(202) 512-3604
farrellb@gao.gov

 

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Does DOD have the right number and right kinds of medical personnel for wartime?

While peacetime medical care is important, a Senate committee and DOD are concerned that prioritizing it has made the military health system less able to treat combat injuries.

The Army, Navy, and Air Force do not have a common method to determine the number and kinds of medical personnel needed for wartime. We also found that DOD has not based its method for measuring medical personnel readiness on sound data or calculated the cost of attaining readiness goals.

We made 6 recommendations, including ways to better estimate the forces needed and assess readiness.

Army medical personnel during a training exercise

Army medical personnel receive instructions during a combat casualty care training exercise

Army medical personnel receive instructions during a combat casualty care training exercise

Additional Materials:

Contact:

Brenda S. Farrell
(202) 512-3604
farrellb@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

What GAO Found

The Department of Defense (DOD) has not determined the required size and composition of its operational medical and dental personnel who support the wartime mission or submitted a complete report to Congress, as required by the National Defense Authorization Act for Fiscal Year 2017. Leaders from the Office of the Secretary of Defense (OSD) disagreed with the military departments' initial estimates of required personnel that were developed to report to Congress. OSD officials cited concerns that the departments had not applied assumptions for operating jointly in a deployed environment and for leveraging efficiencies among personnel and units. GAO found that the military departments applied different planning assumptions in estimating required personnel, such as the definition of “operational” requirements. DOD expects to provide its next update to Congress in February 2019. Until DOD establishes joint planning assumptions for developing medical and dental personnel requirements, including a definition, and a method to assess options for achieving joint efficiencies, DOD will not know whether it has the optimal requirements to achieve its missions.

DOD has begun initiatives to maintain the critical wartime readiness of medical providers. DOD's initiatives have included standardizing and expanding pre-deployment training and developing new policy on medical provider readiness. In addition, department leaders have been directing transformation efforts to improve readiness. However, DOD's methodology is limited with respect to a key initiative that will use a metric to assess medical providers' clinical readiness—a component of wartime readiness. Specifically:

DOD does not use complete, accurate, and consistent data that fully demonstrate results. Source data for the metric have not passed DOD audits for at least 3 years, and the metric does not assess the readiness of reservists who comprise a substantial portion of combat casualty care capability. Also, according to congressional testimony and related research an estimated 25 percent of combat deaths were potentially preventable but were not related to provider readiness. Thus, the metric may not lead to expected improvements in patient outcomes in operational environments. Until DOD identifies and mitigates limitations in the readiness metric data, leaders may not have the best information to support decision-making.

DOD has not made decisions about the specialties to which its metric should apply or budgeted for full implementation of the metric. DOD plans to develop a metric for 72 provider specialties. However, GAO found that 12 specialties do not deploy. According to OSD officials, few of the 72 specialties (i.e., those that practice combat casualty care) rely on highly complex skills that may rapidly degrade without regular practice and would benefit most from a metric. DOD officials stated that the metric's implementation costs may be substantial and the return on investment may differ by specialty. Moreover, DOD has not fully budgeted for implementing the metric by, for example, funding additional training for providers to meet readiness thresholds. Until DOD determines the critical wartime medical specialties to apply its clinical readiness metric and estimates the costs and benefits of applying the metric to each, it will not know if its implementation is being targeted to the areas of greatest return on investment.

Why GAO Did This Study

In recent years, the Senate Armed Services Committee and DOD have raised concerns that the military health system has prioritized peacetime care to the detriment of combat casualty care capability and wartime medical skills.

Senate Report 115-125 included a provision for GAO to review DOD's efforts to address requirements from the National Defense Authorization Act for Fiscal Year 2017 regarding the required numbers of medical and dental personnel and wartime readiness. This report examines the extent to which DOD has (1) determined and reported to Congress on its operational medical and dental personnel requirements, and (2) initiatives to maintain and a methodology to assess the critical wartime readiness of medical providers. GAO reviewed DOD reports and personnel requirements data for fiscal year 2017 and future years, and interviewed senior DOD leaders as well as officials at six military treatment facilities to represent each military department and provide a mix of patient volumes.

What GAO Recommends

GAO is making six recommendations, including that DOD establish joint planning assumptions and a definition, and a method for assessing medical and dental personnel requirements; identify and mitigate limitations in a clinical readiness metric for medical providers; and determine specialties and estimate costs and benefits for applying a readiness metric. DOD concurred with all six recommendations and described implementation steps it plans to take.

For more information, contact Brenda S. Farrell at (202) 512-3604 or farrellb@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director, CAPE, the Joint Staff Surgeon, and the secretaries of the military departments, establish joint planning assumptions for developing operational medical and dental personnel requirements, including a definition of what forces should and should not be identified as "operational." (Recommendation 1)

    Agency Affected: Department of Defense

  2. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of Cost Assessment and Program Evaluation, the Joint Staff Surgeon, and the secretaries of the military departments, establish a method to assess options for achieving joint efficiencies in medical and dental personnel requirements and any associated risks. (Recommendation 2)

    Agency Affected: Department of Defense

  3. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of Cost Assessment and Program Evaluation, the Joint Staff Surgeon, and the secretaries of the military departments, apply joint planning assumptions and a method for assessing efficiencies and risk, use these to determine operational medical and dental requirements, and report to Congress. (Recommendation 3)

    Agency Affected: Department of Defense

  4. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments, identify and mitigate limitations in the clinical readiness metric, such as data reliability, a lack of complete information on reserve component providers and patient care workload performed outside of medical treatment facilities (MTFs), and the lack of linkage between the metric and patient care and retention outcomes. (Recommendation 4)

    Agency Affected: Department of Defense

  5. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the Defense Health Agency, determines which critical wartime specialties perform high-risk, high-acuity procedures and rely upon perishable skill sets and use this information to prioritize specialties to which the clinical readiness metric could be expanded (Recommendation 5).

    Agency Affected: Department of Defense

  6. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with each of the Surgeons General of the military departments and the Director of the Defense Health Agency, estimates the cost and benefits, by specialty, of implementing a clinical readiness metric and use that information to determine whether DODs approach should be revised. Costs to be considered should include those needed to provide additional training for medical personnel to achieve clinical readiness thresholds and to hire additional civilian personnel in MTFs to backfill military providers who leave to attend training. (Recommendation 6)

    Agency Affected: Department of Defense

 

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