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Defense Health Care: Additional Assessments Needed to Determine Effects of Active Duty Medical Personnel Reductions

GAO-23-106094 Published: Jul 11, 2023. Publicly Released: Jul 11, 2023.
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Fast Facts

The Department of Defense has about 108,000 active duty medical personnel who provide health care on the battlefield and in military hospitals and clinics across the nation.

In 2021, DOD proposed reducing the number of military medical personnel by over 10,000.

These reductions could make it harder for the military health system to provide quality care and could affect the cost of that care. But DOD hasn't fully or consistently assessed the potential effects—so it doesn't know for sure.

We recommended fully assessing potential effects before making personnel reduction decisions.

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Highlights

What GAO Found

The Department of Defense (DOD) has not fully or consistently assessed the effects of potential reductions of active duty medical personnel. DOD identified 12,801 military positions to reduce or realign, of which the majority are medical positions. Various medical specialties were selected for reduction, including about 1,000 positions for specialties that are critical for wartime or behavioral health. To mitigate the effect these reductions may have on military medical treatment facilities (MTFs), DOD developed mitigation strategies. These include hiring civilian or contractor replacements, relying on remaining staff to absorb the workload, and sending patients to civilian provider networks under its TRICARE health plan. DOD performed limited assessments on the effect these reductions may have on MTFs. However, DOD did not always consider the feasibility of its mitigation strategies—such as the ability of TRICARE networks to meet any increase in demand for healthcare—because it did not have guidance about how to assess these effects on MTFs. Until DOD develops and uses guidance to comprehensively assess the potential effect that reductions may have on MTFs, it risks taking actions that could decrease the ability of the military health system to achieve its mission of ensuring the medical readiness of the force and caring for military service members and their families.

Proposed Military Positions to Reduce or Realign by Type, Fiscal Years 2020-2027

Proposed Military Positions to Reduce or Realign by Type, Fiscal Years 2020-2027

DOD developed a methodology for evaluating the adequacy of TRICARE networks, but did not use it to assess the ability of these networks to absorb the potential additional patient workload resulting from MTF medical personnel reductions. Instead, DOD reported the results of a population assessment that did not use its methodology. Moreover, DOD did not provide guidance for using its methodology, such as by defining specific measurable objectives that can facilitate consistent assessment of the TRICARE networks surrounding the 215 MTFs affected by the reductions. Until DOD develops and implements such guidance, decision makers risk not knowing the effect, if any, reductions may have on the TRICARE networks.

The military departments used wartime scenarios to determine active duty medical personnel requirements, but did not fully define such requirements prior to determining military medical personnel reductions. Specifically, deficiencies in medical capability exist, in part, because DOD has experienced challenges with recruitment and retention and has undefined medical personnel requirements. For example, DOD has not fully determined the medical personnel needed to support casualties returning from an overseas large-scale conflict. Without fully defined requirements, DOD will not have all relevant information to make decisions regarding the reduction of military medical personnel.

Why GAO Did This Study

DOD relies on more than 108,000 active duty personnel to provide both operational medical care in support of war and other contingencies and beneficiary medical care within the department's hospitals. In 2021, DOD proposed to reduce the number of military medical personnel to increase positions for other missions.

The National Defense Authorization Act for Fiscal Year 2022 included a provision for GAO to review DOD's analyses in support of the reduction or realignment of military medical personnel. This report evaluates the extent to which DOD (1) identified reductions or realignment of active duty medical personnel and strategies to mitigate any potential gaps in health care services at MTFs and assessed any effects; (2) assessed the ability of TRICARE networks to absorb the additional workload that may be caused by reductions; and (3) used wartime scenarios and identified medical capability deficiencies, if any, to determine active duty medical personnel requirements.

GAO analyzed DOD documentation about reduction assessments and medical personnel requirements. GAO also met with cognizant DOD officials.

Recommendations

GAO is making nine recommendations, including that DOD (1) develop and use guidance to assess the effects of military medical personnel reductions on MTFs and the ability of TRICARE networks to absorb additional workload resulting from reductions and (2) fully define requirements before deciding on reductions. DOD concurred with all nine recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Defense
Priority Rec.
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 DHA, develops and implements department-wide guidance for assessing fully and consistently the potential effect of military medical personnel reductions on the MTFs, including procedures for documenting results of the assessments. Such guidance should provide clarity on assessing feasibility of using mitigation strategies for any identified reductions and conducting a risk analysis associated with the hiring, onboarding, and retention of civilian personnel. (Recommendation 1)
Open
DOD agreed with this recommendation, but has not yet implemented this recommendation. In December 2023, the Deputy Secretary of Defense issued a memorandum about stabilizing and improving the military health system. This memo directs numerous actions related to assessing and documenting medical personnel and staffing requirements. As of May 2024, the Under Secretary of Defense for Personnel and Readiness (USD(P&R)) is planning to complete a comprehensive review of all medical personnel and staffing requirements by the end of June 2024. Further, according to the memorandum, the USD(P&R), in coordination with the military departments, will begin implementing the approved findings in a study about future strategies for the military health system. The memorandum states that DOD is planning to begin redistribution efforts by July 1, 2024, and these efforts are intended to distribute military medical personnel, optimize clinical readiness and care opportunities, and continue supporting critical operational needs. DOD estimates this recommendation will be fully implemented by July 2025. We will continue to monitor DOD's actions to implement this recommendation.
Department of Defense The Secretary of the Army, in coordination with the Surgeon General of the Army, should use the results of such assessments to inform the number of active duty medical personnel reductions. (Recommendation 2)
Open
DOD concurred with this recommendation, but has not yet implemented this recommendation. In December 2023, the Deputy Secretary of Defense issued a memorandum about stabilizing and improving the military health system. This memo directs numerous actions related to assessing and documenting medical personnel and staffing requirements. The memorandum directs the development of policy and business rules to holistically evaluate and adjudicate risk to medical manpower requirements across the department. In a March 2024 status update, DOD stated that the Army will use the results of the assessments to inform the number of active-duty medical personnel reductions. DOD estimates this recommendation will be fully implemented by July 2025. We will continue to monitor DOD and the Army's actions to implement this recommendation.
Department of Defense The Secretary of the Navy, in coordination with the Surgeon General of the Navy, should use the results of such assessments to inform the number of active duty medical personnel reductions. (Recommendation 3)
Open
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a March 2024 status update, DOD stated that upon completion of guidance for assessments and actions discussed in recommendation 1, the Navy should be able to proceed with completing its assessments on military medical personnel reductions. According to DOD, the Navy will use results of the assessments to inform the number of active-duty medical personnel reductions and determine whether future active-duty medical personnel reductions are feasible. Furthermore, in December 2023, the Deputy Secretary of Defense issued a memorandum about stabilizing and improving the military health system. This memo directs numerous actions related to assessing and documenting medical personnel and staffing requirements. The memorandum directs the development of policy and business rules to holistically evaluate and adjudicate risk to medical manpower requirements across the department. DOD estimates this recommendation will be fully implemented by July 2025. We will continue to monitor DOD and the Navy's actions to implement this recommendation.
Department of Defense The Secretary of the Air Force, in coordination with the Surgeon General of the Air Force, should use the results of such assessments to inform the number of active duty medical personnel reductions. (Recommendation 4)
Open
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a March 2024 status update, DOD stated that upon completion of guidance for assessments and actions discussed in recommendation 1, the Air Force should be able to proceed with completing its assessments on military medical personnel reductions. According to DOD, the Air Force will use results of the assessments to inform the number of active-duty medical personnel reductions and determine whether future active-duty medical personnel reductions are feasible. Furthermore, in December 2023, the Deputy Secretary of Defense issued a memorandum about stabilizing and improving the military health system. This memo directs numerous actions related to assessing and documenting medical personnel and staffing requirements. The memorandum directs the development of policy and business rules to holistically evaluate and adjudicate risk to medical manpower requirements across the department. DOD estimates this recommendation will be fully implemented by July 2025. We will continue to monitor DOD and the Air Force's actions to implement this recommendation.
Department of Defense 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 DHA, conducts a comprehensive assessment of the cost of any future proposed military medical personnel reductions on the unified medical budget and use that assessment to inform reduction decisions. (Recommendation 5)
Open
DOD concurred with this recommendation, but has not yet implemented this recommendation. In December 2023, the Deputy Secretary of Defense issued a memorandum about stabilizing and improving the military health system. This memo directs numerous actions related to assessing and documenting medical personnel and staffing requirements. The memorandum directs the development of policy and business rules to holistically evaluate and adjudicate risk to medical manpower requirements across the department. In a March 2024 status update, DOD estimates this recommendation will be fully implemented by December 2026. We will continue to monitor DOD's actions to implement this recommendation.
Department of Defense 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 DHA, develops guidance that translates the 719 Plan methodology into a process with measureable objectives that can facilitate consistent assessments of TRICARE networks' ability to absorb additional patient workload resulting from future reductions of military medical personnel. (Recommendation 6)
Open
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a March 2024 status update, DOD stated that the Defense Health Agency (DHA) will review the tracking and monitoring of TRICARE network access to care by specialties and locality to ensure it is appropriate. This monitoring is measuring network adequacy (e.g., wait time from referral to appointment), enrollee drive times to care by specialty, and cost. Furthermore, DOD noted that Health Affairs, in coordination with DHA and the MILDEPs, will develop an Military Health System manpower review and assessment process. Assessments of TRICARE's ability to absorb patient workload will be part of this process. DHA will provide the methodology for TRICARE's ability to absorb additional patient workload and predict network adequacy. DOD estimates this recommendation will be fully implemented by December 2025. We will continue to monitor DOD's actions to implement this recommendation.
Department of Defense 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 DHA, prior to implementing its future military medical personnel reductions plans, assesses TRICARE networks with planned military medical personnel reductions using guidance developed from the 719 Plan methodology to determine the networks' ability to absorb additional patient workload. (Recommendation 7)
Open
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a March 2024 status update, DOD stated that the Defense Health Agency (DHA) will review the tracking and monitoring of TRICARE network access to care by specialties and locality to ensure it is appropriate. Furthermore, DOD plans to assess the TRICARE networks' ability to absorb additional patient workload during the manpower review and assessment process, which will be woven into the annual program budget review cycle. A Directive-Type Memorandum that will codify the process. DOD estimates this recommendation will be fully implemented by December 2025. We will continue to monitor DOD's actions to implement this recommendation.
Department of Defense 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 DHA, uses the guidance developed from the 719 Plan methodology and develops a plan that facilitates periodic monitoring of the ability of TRICARE networks to absorb additional patient workload resulting from any planned military medical personnel reductions. (Recommendation 8)
Open
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a March 2024 status update, DOD stated that the Defense Health Agency (DHA) will review the tracking and monitoring or TRICARE network access to care by specialties and locality to ensure it is appropriate. This monitoring is measuring network adequacy (e.g., wait time from referral to appointment), enrollee drive times to care by specialty, and cost. Assessments of TRICARE's ability to absorb patient workload will be part of this process. DHA plans to provide the methodology for TRICARE's ability to absorb additional patient workload and predict network adequacy. DOD estimates this recommendation will be fully implemented by December 2025. We will continue to monitor DOD's actions to implement this recommendation.
Department of Defense The Secretary of Defense, in coordination with the Chairman of the Joint Chiefs of Staff and the Secretaries of the military departments, should ensure that DOD fully defines military medical personnel requirements before making future decisions about how many military medical personnel to reduce and where to accept risk. (Recommendation 9)
Open
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a March 2024 status update, DOD stated that it will complete a comprehensive manpower review to validate the military essentiality of active-duty medical personnel in fulfilling both operational medicine and health services delivery requirements effectively. In addition, by June 2025, DOD plans to complete an update on operational plans to validate the total medical force requirements for large-scale overseas conflict and homeland casualty care management. According to DOD, this will help make informed decisions on the total military medical end strength to sustain in quantities of specific wartime medical specialties. DOD estimates this recommendation will be fully implemented by December 2025. We will continue to monitor DOD's actions to implement this recommendation.

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