Defense Health Care: Additional Assessments Needed to Better Ensure an Efficient Total Workforce

GAO-19-102 Published: Nov 27, 2018. Publicly Released: Nov 27, 2018.
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Fast Facts

Over 241,000 people work in DOD's health system, which reaches from the battlefield to large hospitals in the United States. The workforce includes active and reserve military, federal civilian staff, and private sector contractors.

Officials we spoke with at 5 of 6 selected military hospitals reported having to send patients outside the system for medical care due to challenges including:

civilian hiring freezes

lengthy hiring and contracting processes.

We recommended that the Defense Health Agency, which is in the process of assuming control of DOD hospitals and clinics, develop a strategic workforce plan to address these challenges.

Army medical personnel during a training exercise

Two Army medical personnel treat a mock patient during a training exercise.

Two Army medical personnel treat a mock patient during a training exercise.

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Highlights

What GAO Found

The military departments each have their own processes to determine their operational medical personnel requirements; however, their planning processes to meet those requirements do not consider the use of all medical personnel or the full cost of military personnel. Specifically:

  • The Department of Defense (DOD) has not assessed the suitability of federal civilians and contractors to meet operational medical personnel requirements. Federal civilians and contractors play key roles in supporting essential missions, i.e. providing operational assistance via combat support. Military department officials expressed a preference for using military personnel and cited possible difficulties in securing federal civilian and contractor interest in such positions. An assessment of the suitability of federal civilians and contractors could provide options for meeting operational medical personnel requirements.
  • When determining the balance of active and reserve component medical personnel, the military departments' processes generally do not consider full personnel costs, including education and benefits. Specifically, officials stated that the Army and the Navy do not consider personnel costs in their assessment of the appropriate balance between active and reserve personnel, and the Air Force's analysis had some limitations. DOD policy states that workforce decisions must be made with an awareness of the full costs. Further, in a 2013 report, DOD identified the cost of unit manning, training, and equipping as one of five factors that play a key role in decisions concerning the mix of active and reserve component forces. By developing full cost information for active and reserve component medical personnel, DOD can better ensure an appropriate and cost-effective mix of personnel.

The military departments have taken actions, such as establishing policies and procedures, to assess the appropriate workforce mix for beneficiary care within Military Treatment Facilities (MTFs), but challenges remain. The military departments distribute military personnel across the MTFs and then use policies and procedures to consider risks, costs, and benefits to determine how to fill the remaining positions with federal civilians and contractors. However, a number of challenges, including lengthy hiring and contracting processes and federal civilian hiring freezes affect DOD's ability to use federal civilians and contractors. For example, senior officials at each of the six MTFs that GAO spoke with cited challenges with the federal civilian hiring process, and five of six MTFs cited challenges with the contracting process. As a result, senior officials from five of six MTFs reported discontinuing some services and referring patients to DOD's TRICARE network of private sector providers or Veterans Affairs facilities. The Military Health System (MHS) is also preparing for the phased transfer of administrative responsibility for MTFs to the Defense Health Agency (DHA), including management of the MTF workforce. According to GAO's report on agency reform efforts, strategic workforce planning should precede any staff realignments or downsizing. However, according to a senior official, the DHA has not developed a strategic workforce plan. Without developing such a plan, the DHA may continue to face the same challenges experienced by the military departments in executing an appropriate and efficient workforce mix at its MTFs.

Why GAO Did This Study

The MHS includes more than 241,000 active duty, reserve, federal civilian, and contractor personnel who provide (1) operational medical care in support of war and other contingencies and (2) beneficiary medical care within DOD's hospitals and clinics.

The Senate Report 115-125 accompanying a bill for the National Defense Authorization Act for Fiscal Year 2018 contained a provision for GAO to review how DOD determines its mix of military, federal civilian, and contractor personnel. This report examines the military departments' planning processes for determining (1) operational medical personnel requirements, including an assessment of the mix of federal civilian, contractor, and active and reserve medical personnel; and (2) the most appropriate workforce mix at MTFs and any challenges in executing their desired workforce mix. GAO compared MHS staffing practices with DOD policy, and analyzed fiscal year 2017 budgetary data to determine the proportion of military, federal civilian, and contractor personnel. GAO also interviewed senior leaders at six MTFs.

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Recommendations

GAO recommends that DOD, among other things, (1) assess the suitability of federal civilians and contractors to provide operational medical care; (2) develop full cost information for active and reserve component medical personnel; and (3) develop a strategic total workforce plan for the DHA to help ensure execution of an appropriate workforce mix at its MTFs. In commenting on a draft of this report, DOD concurred with each of GAO's recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Defense The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the military departments, perform an assessment of the suitability of federal civilian and contractor personnel to provide operational medical care and incorporate the results of the assessment into relevant policies, if warranted. (Recommendation 1)
Open
The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of April 2022, DOD has not yet implemented this recommendation, citing ongoing Congressionally directed reforms of the Military Health System. It provided an estimated implementation date of June 2023.
Department of Defense The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness require consideration of cost when making determinations regarding the mix of active and reserve component medical personnel. (Recommendation 2)
Open
The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of April 2022, DOD has taken some steps to implement this recommendation. Specifically, in an April 2022 update, DOD stated that it has engaged the Institute for Defense Analyses to study the issue of "Total Force costing," and the study is expected to conclude in March 2024. It further stated that following the conclusion of the study, DOD will be able to update its costing factors in policy and guidance.
Department of Defense The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in collaboration with the Director of Cost Assessment and Program Evaluation and the military departments, develop full cost information for active and reserve component medical personnel, and the military departments use that information in its determinations regarding the mix of active and reserve component medical personnel. (Recommendation 3)
Open
The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of April 2022, DOD has taken some steps to implement this recommendation. Specifically, in an April 2022 update, DOD stated that it has engaged the Institute for Defense Analyses to study the issue of "Total Force costing," and the study is expected to conclude in March 2024. It further stated that following the conclusion of the study, DOD will be able to update its costing factors in policy and guidance.
Department of Defense The Secretary of Defense should ensure that the Director of the Defense Health Agency develop a strategic total workforce plan which includes, among other things: (1) tailored human capital strategies, tools, and metrics by which to monitor and evaluate progress toward reducing personnel gaps, and; (2) integration of human capital strategies with acquisition plans, such as DOD's acquisition strategy for health care services at DOD's military treatment facilities. (Recommendation 4)
Open
The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of April 2022, DOD has not yet implemented this recommendation, citing ongoing Congressionally directed reforms of the Military Health System. It provided an estimated implementation date of December 2022.
Department of Defense The Secretary of Defense and the Secretaries of the Army, the Navy, and the Air Force, respectively, should ensure that accompanying the transfer of administrative responsibility for military treatment facilities to the Defense Health Agency, that the Defense Health Agency and the military departments develop policies and procedures for management of military personnel, including agreement on specific roles and responsibilities for the military departments and the Defense Health Agency in this process. (Recommendation 5)
Open
The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of April 2022, DOD has not yet implemented this recommendation, citing ongoing Congressionally directed reforms of the Military Health System. It provided an estimated implementation date of December 2022.

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