Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should expand the scope of the department's centralized database on problematic sexual behavior in children and youth, which is under development, to also track information on all incidents involving the abuse of a child (physical, sexual, emotional, and neglect) reported to the Family Advocacy Program or investigated by a military law enforcement organization, regardless of whether the offender was another child, an adult, or someone in a noncaregiving role at the time of the incident. (Recommendation 1)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD did not concur with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should, as part of the ongoing development of the centralized database, identify and define the elements to be tracked by each responsible organization, such as the Family Advocacy Program and military law enforcement. (Recommendation 2)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should develop a plan for how it will use the data it will collect in the centralized database to help ensure data-driven decision-making is used to inform program efforts. (Recommendation 3)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should establish a reliable schedule for the development and implementation of the centralized database on problematic sexual behavior in children and youth that includes key activities, the timeframes and resources needed to execute them, and GAO-identified practices for developing and maintaining a reliable schedule. (Recommendation 4)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should direct the service Family Advocacy Programs and military law enforcement organizations to document in their respective databases the date that they notified the other entity of a reported incident of child abuse. (Recommendation 5)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should issue guidance that describes the process through which the service Family Advocacy Programs are to receive and incorporate information into their central registries regarding child abuse allegations and determinations involving their servicemembers and dependents that were recorded by another service's installation Family Advocacy Program. Such guidance should include a mechanism to monitor that the process is occurring consistently. (Recommendation 6)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Army should develop a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 7)

Agency: Department of Defense: Department of the Army: Office of the Secretary
Status: Open

Comments: The Army concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should develop a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 8)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should ensure that the Commandant of the Marine Corps develops a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 9)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Air Force should develop a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 10)

Agency: Department of Defense: Department of the Air Force: Office of the Secretary of the Air Force
Status: Open

Comments: The Air Force concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of the Department of Defense Education Activity, clarifies Department of Defense Education Activity guidance to define what types of incidents must be reported as "serious incidents" to help ensure that all serious incidents of which Department of Defense Education Activity leadership needs to be informed are accurately and consistently reported by school administrators. (Recommendation 11)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should expand the voting membership of the Incident Determination Committee to include medical personnel with the requisite knowledge and experience. (Recommendation 12)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Army should establish efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 13)

Agency: Department of Defense: Department of the Army: Office of the Secretary
Status: Open

Comments: The Army concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should establish efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 14)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should ensure that the Commandant of the Marine Corps establishes efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 15)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Air Force should establish efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 16)

Agency: Department of Defense: Department of the Air Force: Office of the Secretary of the Air Force
Status: Open

Comments: The Air Force concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should clarify, in guidance, the circumstances under which commanders may exercise their authority to remove a child from a potentially unsafe home on an overseas installation. (Recommendation 17)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of the Defense Health Agency, establishes processes that help ensure children who are sexually abused overseas have timely access to a certified pediatric sexual assault forensic examiner to conduct the examination. Initiatives could include certifying pediatricians or adult sexual assault forensic examiners as pediatric examiners during mandatory training or establishing shared regional assets. (Recommendation 18)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Deputy Attorney General, should seek avenues to improve communication between the military criminal investigative organizations and United States Attorneys for relevant cases involving child victims to help ensure that investigators are notified when prosecution is declined, including the reasons for the declination when appropriate, such as details about any investigative deficiencies. (Recommendation 19)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Army should seek to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Army installations and thereby increase awareness of those services across the department. (Recommendation 20)

Agency: Department of Defense: Department of the Army: Office of the Secretary
Status: Open

Comments: The Army partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should continue to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Navy installations and thereby increase awareness of those services across the department. (Recommendation 21)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should ensure that the Commandant of the Marine Corps continues to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Marine Corps installations and thereby increase awareness of those services across the service. (Recommendation 22)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Air Force should seek to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Air Force installations and thereby increase awareness of those services across the department. (Recommendation 23)

Agency: Department of Defense: Department of the Air Force: Office of the Secretary of the Air Force
Status: Open

Comments: The Air Force concurred with this recommendation. As of April 2020, this recommendation remains open.

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: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. According to department officials, as of November 2019, they are drafting a report that will address this recommendation. We will continue to monitor DOD's efforts.

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: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. According to department officials, as of November 2019, they are drafting a report that will address this recommendation. We will continue to monitor the department's efforts. .

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: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. According to department officials, as of November 2019, they are drafting a report that will address this recommendation. We will continue to monitor DOD's efforts..

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: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of November 2019, DOD has not taken any actions to implement this recommendation.

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: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of November 2019, DOD has not implemented this recommendation.

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: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of November 2019, DOD has not implemented this recommendation.

Recommendation: 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)

Agency: Department of Defense
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 require consideration of cost when making determinations regarding the mix of active and reserve component medical personnel. (Recommendation 2)

Agency: Department of Defense
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 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)

Agency: Department of Defense
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 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)

Agency: Department of Defense
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 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)

Agency: Department of Defense
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 the Army should develop targeted strategies for using its recruitment, training, and retention programs collectively to address key military physician gaps in a coordinated manner, and metrics that would monitor the effectiveness of its programs collectively in reducing gaps. (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: Army concurred with this recommendation. In October 2019, the Army reported that several steps have been taken, including creating a 6-year health professions officer retention bonus for critically short physician specialties; increased the number of Health Professions Scholarship Program scholarships to help decrease the overall physician shortfalls; and added a recruiting mission using Financial Assistance Program (FAP) scholarships to help decrease the physician shortfall in critical specialties. The FAP mission is to begin in fiscal year 2020. While the steps Army reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Navy should develop targeted strategies for using its recruitment, training, and retention programs collectively to address key military physician gaps in a coordinated manner, and metrics that would monitor the effectiveness of its programs collectively in reducing gaps. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: Navy concurred with this recommendation. In October 2019, Navy officials stated that several steps have been taken, including exploring policy changes that would assist in meeting requirements. According to Navy officials, a working group has been formed which will address recruitment and retention of all critical specialties and plan to issue an end product by June 2020.

Recommendation: The Secretary of the Air Force should develop targeted strategies for using its recruitment, training, and retention programs collectively to address key military physician gaps in a coordinated manner, and metrics that would monitor the effectiveness of its programs collectively in reducing gaps. (Recommendation 3)

Agency: Department of Defense
Status: Open

Comments: Air Force concurred with our recommendation. In October 2019, the Air Force reported that several steps have been taken; including developing a sustainable process for improved marketing of key specialties to students and increasing the number of Health Professions Scholarship Program scholarships. While the steps Air Force reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Navy should track complete, accurate, and accessible information on the qualifications, performance, and progress of Navy AFHPSP medical students. (Recommendation 5)

Agency: Department of Defense
Status: Open

Comments: Navy concurred with this recommendation. In November 2018, the Navy changed its Navy Standard Integrated Personnel System (NSIPS) to allow tracking of qualification data fields. As of October 2019, the Navy reported it is taking steps to update NSIPS to track the complete performance and progress of AFHPSP medical students. While the steps Navy reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Air Force should track complete, accurate, and accessible information on the qualifications, performance, and progress of Air Force AFHPSP medical students. (Recommendation 6)

Agency: Department of Defense
Status: Open

Comments: Air Force concurred with this recommendation. In August 2018, the Air Force updated guidance to emphasize the requirement for accurate and complete reporting of qualification data of AFHPSP medical students. As of October 2019, the Air Force reported that it is partnering with the Army and Navy to secure a tri-service database to track students' performance across the continuum of learning. While the steps Air Force reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The President of Uniformed Services University of the Health Sciences (USUHS) should track complete, accurate, and accessible information on the performance and progress of USUHS medical students. (Recommendation 7)

Agency: Department of Defense
Status: Open

Comments: Uniformed Services University of the Health Sciences concurred with our recommendation. In October 2019, the University reported that issues relevant to tracking its students continue to be researched and have offered to collaborate with the military departments. While the steps the University reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Navy should use information on medical student performance to evaluate Navy accession programs. (Recommendation 8)

Agency: Department of Defense
Status: Open

Comments: Navy concurred with this recommendation. In October 2019, the Navy reported that the Navy Standard Integrated Personnel System (NSIPS) now contains qualification data of AFHPSP medical students and also has some performance data of these students as they compete their post graduate training. NPSIS is capable of being queried and this data, according to the Navy, can be used to evaluate its accession programs. While the steps Navy reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Air Force should use information on medical student performance to evaluate Air Force accession programs. (Recommendation 9)

Agency: Department of Defense
Status: Open

Comments: Air Force concurred with our recommendation. In October 2019, the Air Force reported it plans to annually track and analyze information regarding its AFHPSP medical students and it is in the process of performing its annual review. While the steps Air Force reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Undersecretary for Health should develop and implement a process to accurately count all physicians providing care at each medical center, including physicians who are not employed by VHA. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open
Priority recommendation

Comments: As of January 2020, VHA continues to disagree with the recommendation and has not taken any action. Although VA responded to our report by stating that the ability to count physicians does not affect its ability to assess workload, we maintain that an accurate count of all physicians providing care at each medical center is necessary for accurate workforce planning. To implement the first recommendation, VHA needs to develop a system-wide process to collect information on all physicians providing care at VAMCs, including physicians that are not employed by VHA. This information should be available at the local level for workforce planning purposes.

Recommendation: The Undersecretary for Health should develop and issue guidance to the VAMCs on determining appropriate staffing levels for all mission-critical physician occupations. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation. In November 2017, VHA's Executive in Charge chartered the Specialty Care Provider Staffing and Network Model Workgroup to develop a methodology for determining the scope and complexity of specialty care services. The Workgroup also developed an analytical tool to support local decision-making around specialty staffing levels. According to VHA, the Specialty Care Services Staffing model has been validated across some VHA regions. The Workgroup was directed to develop an Executive Decision Memorandum for an official determination as to implementation of the model. As of January 2020, VHA was awaiting the results of the Governing Board's decision on the Executive Decision Memorandum, the guidance documents, and analytical template. VHA reported the target date for completion is March 2020.

Recommendation: The Undersecretary for Health should establish a system-wide method to share information about physician trainees to help fill vacancies across VAMCs. (Recommendation 4)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation. VHA is working to develop the necessary capacity to enable a system-wide method for sharing information about physician trainees to help fill vacancies. In April 2019, VHA anticipated having this system in place by the end of fiscal year 2019. However, VHA has not submitted any additional information since April 2019. VHA has also created a VHA-Trainee Recruitment and Hiring Workgroup (the Workgroup). The Workgroup serves as the advisory group on trainee recruitment and hiring, for the purpose of developing a permanent Trainee Recruitment and Hiring Function. The Workgroup is holding Virtual Trainee Recruitment Events for critical occupations. Until GAO sees evidence of a system-wide method for sharing information about physician trainees, this recommendation will remain open.

Recommendation: The Secretary of HHS should expeditiously develop a plan--that includes priorities, timeframes, clear roles and responsibilities, and methods for assessing progress--to effectively implement the NAS-related recommendations identified in the Protecting Our Infants Act: Final Strategy. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: HHS concurred with this recommendation. HHS' Behavioral Health Coordinating Council finalized a plan for implementing the Strategy in 2019 . The plan includes priorities, timeframes, and clear roles and responsibilities for implementing NAS-related recommendations in the Strategy. The plan does not specifically identify methods for assessing progress on the recommendations, but HHS officials told us in November 2019 that the department holds quarterly conference calls to share updates and formal written updates will be collected at the end of each year. To close this recommendation, HHS needs to provide documentation-such as, the formal written updates-to show how the department assesses progress on the recommendations.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to, in coordination with the Director, USMEPCOM, establish a schedule to repair the internal EPTS database so that USMEPCOM can provide more regular and specific feedback to MEPS chief medical officers.

Agency: Department of Defense
Status: Open

Comments: In its comments to this recommendation, DOD concurred with this recommendation and said that the database was inoperable but that it was being reviewed as part of a multi-year information technology modernization effort to transition all military medical records to a new system known as MHS (Military Health System) GENESIS. They noted that the capability for USMEPCOM to conduct EPTS medical records review would be available within MHS GENESIS' business intelligence tools once implemented. When asked about the status of any actions taken to address this recommendation by preparing a schedule as to when this internal database would be repaired, DOD responded in January 2018 that USMEPCOM is unable to expend any funds to repair or replace the EPTS database system as this functionality is to be incorporated into the upcoming MHS GENESIS program. DOD officials confirmed that USMEPCOM's initial site testing will occur in FY 2019. While DOD officials are not able to repair its current internal database needed to complete its statistical analysis of these particular medical records, MHS GENESIS will be able to provide USMEPCOM with this capability. In August 2019, a senior DOD official confirmed that using MHS GENESIS is still the primary course of action to address this recommendation. He said that its implementation is planned for 2020/2021; however, there has been another delay and the department is waiting for a new implementation date to be established. In May 2020, this same official provided updated information that said MHS Genesis was delayed until 2021. Therefore, until further progress is made in implementing MHS GENESIS, this recommendation should remain open.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to, in coordination with the Under Secretary of Defense for Acquisition, Technology, and Logistics and the DOD Healthcare Management Systems Program Executive Office, develop a schedule of actions for deploying its new electronic health record system, MHS GENESIS, within USMEPCOM that includes key activities such as the major actions required to accomplish this effort, completion dates for all actions leading up to these events, and dates for the system's deployment to MEPS locations.

Agency: Department of Defense
Status: Open

Comments: In its comments to this recommendation, DOD partially concurred and stated that it began fielding MHS GENESIS and anticipated issuing a Full Deployment Decision (FDD) certification in 2018 to proceed to the remaining sites. Further, when asked about the status of any actions taken to address this recommendation, DOD responded in January 2018 that USMEPCOM's inclusion in MHS GENESIS is scheduled for approval in late fiscal year 2018 with initial MEPS site testing in fiscal year 2019. According to DOD, USMEPCOM officials are working closely with the program management officials and the MHS GENESIS team to develop information requirements for approval and inclusion in the MHS GENESIS deployment plan once FDD is granted. The estimated completion date for the roll out to all remaining MEPS locations is fiscal year 2021. In August 2019, a senior DOD official confirmed that the department's primary course of action for addressing this recommendation remains the use of MHS GENESIS. However, he said that DOD has experience a delay and in May 2020, he stated that MHS Genesis had been delayed until FY 21. Given that DOD is still in the process of deploying MHS GENESIS, we believe this recommendation should remain open until progress has been made in implementing the MHS Genesis within the MEPS locations.

Recommendation: To help ensure that HHS agencies and offices fully understand the requirements and processes for the temporary reassignment authority, their responsibilities under the authority, and that ASPR is adequately and comprehensively assessing the effect of the authority on public health emergency response and medical surge, the Secretary of HHS should direct ASPR to conduct outreach to HHS agencies and offices that administer programs eligible for the reassignment authority to inform them of their responsibilities and ASPR's expected time frames for reviewing and approving states' and tribes' requests for personnel reassignments, and inform them of their responsibilities and ASPR's expectations for reviewing states' and tribes' after-action reports.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS provided us with information on its efforts to share information about the temporary reassignment authority throughout the department. However, it is not clear that HHS has routed the temporary reassignment standard operation procedures, which provides instructions on how to request use of the authority and documentation and reporting requirements, with the HHS agencies that are likely to be primarily affected.

Recommendation: To fully assess the size and composition of the medical force, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to conduct a new analysis of the required number of active-duty and civilian medical personnel that mitigates known limitations.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2020, DOD has not addressed this recommendation. In response to a provision in Senate Report 115-125, we assessed DOD's interim and final draft responses to a requirement in the National Defense Authorization Act (NDAA) for Fiscal Year 2017 to assess the required number of wartime medical and dental personnel. In our ensuing February 2019 report, we found that DOD had 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. Specifically, 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. We found that the military departments applied different planning assumptions in estimating required personnel, such as the definition of "operational" requirements. Further, although not required by the NDAA for Fiscal Year 2017, DOD's assessment did not include civilian medical personnel. Until DOD completes such an analysis, it cannot be assured that its medical force is appropriately sized.

Recommendation: To strengthen ongoing efforts to analyze the costs of medical force readiness and establish clinical currency standards, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to take steps to identify and mitigate limitations regarding the standard for maintaining providers' clinical skills, including improving the accuracy of information concerning providers' workload and conducting an analytically rigorous calculation of active-duty providers' time devoted to military-specific responsibilities.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2020, DOD has taken steps to address this recommendation, but has not completed all necessary actions. In February 2019, we reported that DOD had begun work on a metric to assess the clinical readiness of providers, but noted that the department's methodology was limited. In particular, the methodology did not provide complete, accurate, and consistent data or fully demonstrate results. Further, although DOD provided documentation in February 2020 outlining the medical specialties to which its clinical readiness metric would apply, it has not fully budgeted for the cost of implementing the metric. DOD's July 2018 report in response to Section 703 of the National Defense Authorization Act for Fiscal Year 2017 notes steps taken to assess the accuracy of information concerning providers' workload, but does not address the time active-duty providers devote to military-specific responsibilities. Until DOD addresses these issues, its efforts to analyze the costs of medical force readiness and establish clinical currency standards will remain limited.

Recommendation: To help achieve DOD's goals for transferring health care into its own facilities and increasing the productivity of active-duty medical providers, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to develop a strategy for achieving these goals that reflects the leading practices of effective federal strategic planning.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020, DOD has not yet addressed this recommendation.

Recommendation: To strengthen ongoing efforts within DOD to address the Study's recommendations to use the provider model outputs to inform execution of health care delivery and to refine the model for future use, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to modify DOD's model to reflect the military service of the physicians and military treatment facilities included in the model.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020 DOD has not implemented this recommendation. In its July 2018 report in response to Section 703 of the National Defense Authorization Act for Fiscal Year 2017, DOD stated in response to this recommendation that facilities in several large Military Health System (MHS) markets are staffed in a multi-service manner. While this is an important point, it remains true that, as the report notes, DOD's model "assumed uniformed providers were interchangeable," and that such an approach does not reflect the single-service nature of most medical treatment facilities within the MHS. Until DOD's model reflects this, the results of its approach will continue to be limited.

Recommendation: To strengthen any future assessments of additional changes to DOD's network of military treatment facilities, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to describe steps taken to assess the reliability of data supporting the assessment, including, at a minimum, the sources of data, data limitations, and efforts to test data reliability.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020, DOD has taken steps to address this recommendation, but has not completed all necessary actions. In its July 2018 report in response to Section 703 of the National Defense Authorization Act for Fiscal Year 2017, DOD included the sources of its data and some data limitations, but not efforts to test data reliability. Until DOD fully incorporates assessments of data reliability into its analysis of future changes to the Military Health System, such as its implementation plan Section 703, it will continue to lack assurance that its approach is fully supported by reliable information.

Recommendation: To strengthen any future assessments of additional changes to DOD's network of military treatment facilities, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to include in any accompanying cost estimates an appropriate level of detail, all significant costs, and an assessment of the reliability of the data supporting the cost estimate.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020, DOD has not addressed this recommendation. As we reported in May 2020, DOD's plan to restructure MTFs in response to Section 703 of the National Defense Authorization Act for Fiscal Year 2017, DOD concluded that civilian health care was more cost-effective than care in its MTFs without considering other assumptions that could affect its conclusions. For example, DOD applied assumptions about the cost of military personnel salaries, MTF workloads, and reimbursement rates for TRICARE that likely underestimated the cost-effectiveness of MTFs. Until DOD's approach to assessing changes to its network of MTFs is accompanied by cost estimates with an appropriate level of detail, all significant costs, and an assessment of the reliability of the data supporting the cost estimate, its approach will remain limited.

Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to assess the Triad of Care model's effectiveness in light of the changes in WTU diagnoses and take the appropriate action.

Agency: Department of Defense: Department of the Army
Status: Open

Comments: The Army concurred with this recommendation. As of August 2020, an Army Medical Command official stated that the Warrior Transition Unit manpower model is under review by the U.S. Army Manpower Analysis Agency and that the scheduled date for the release of the review is unknown.

Recommendation: To help determine whether current efforts are effective or if additional action may be needed, such as development of a workplace violence prevention standard for health care employers, the Secretary of Labor should direct the Assistant Secretary for Occupational Safety and Health to develop and implement cost-effective ways to assess the results of the agency's efforts to address workplace violence.

Agency: Department of Labor
Status: Open
Priority recommendation

Comments: According to OSHA officials, the agency had a study underway to review OSHA's workplace violence enforcement cases in health care to better understand the obstacles OSHA compliance officers encountered during these investigations and identify factors which led to citations. The study was intended to help compliance officers develop citations in workplace violence cases. In addition, in December 2016, OSHA published a Request for Information on Preventing Workplace Violence in Healthcare and Social Assistance (RFI) to help identify workplace violence prevention requirements that could be effective and economical if a regulation were to be developed. OSHA reported in June 2018 that it is evaluating the information it received in response to the RFI and is gathering information on best practices in certain industries. As of April 2020, OSHA completed its review of the submissions in response to the RFI, is developing regulatory options, and will obtain additional input from potentially affected small businesses. The agency anticipates completing this process by the end of 2020. To fully implement this recommendation, the agency should complete its process of obtaining input on the regulatory options the agency is developing, and finalize its determination on whether regulatory action is needed.

Recommendation: In order to prevent the shift of services from physician offices to HOPDs from increasing costs for the Medicare program and beneficiaries, Congress should consider directing the Secretary of HHS to equalize payment rates between settings for E/M office visits--and other services that the Secretary deems appropriate--and to return the associated savings to the Medicare program.

Agency: Congress
Status: Open

Comments: The Bipartisan Budget Act of 2015, enacted in November 2015, partially addressed our recommendation as it limits certain providers from billing at higher hospital outpatient department payment rates. Specifically, the legislation excludes services furnished by off-campus hospital outpatient departments from reimbursement under Medicare's hospital outpatient prospective payment system, effective January 1, 2017. According to the Congressional Budget Office, this action saves the Medicare program $9.3 billion over 10 years. However, the Act does not apply to services furnished by providers billing as hospital outpatient departments prior to enactment of the legislation-which includes providers billing as hospital outpatient departments during the study period in our report-as well as hospital outpatient departments located on hospital campuses. This means that, even in 2017 and beyond, many providers will not be affected by the Act, and Medicare will continue to pay more than necessary for certain services. In November 2018, CMS issued a final rule adopting payment changes-that have since been partially overturned under a decision by a federal district court, which CMS has appealed-capping payment rates for certain services furnished by the off-campus hospital outpatient departments that existed or were under construction in 2015 at the physician fee schedule rate. Since these services furnished by these off-campus hospital outpatient departments were paid under a higher rate, the payment cap, which was to be implemented over 2 years, was intended to equalize payment rates for certain clinical visits between settings. In 2019, CMS applied 50 percent of the payment reduction and in 2020 and subsequent years planned to apply 100 percent of the payment reduction. The rule applied to specific clinical visits; and other services would continue to be paid at the higher rate. However, a federal district court overturned the payment cap in September 2019. CMS has appealed that ruling and adopted a final rule in November 2019 that will implement the payment reduction in 2020. A lawsuit challenging the November 2019 final rule has been filed.

Recommendation: To ensure that HHS workforce efforts meet national needs, the Secretary of Health and Human Services should develop a comprehensive and coordinated planning approach to guide HHS's health care workforce development programs--including education, training, and payment programs--that (1) includes performance measures to more clearly determine the extent to which these programs are meeting the department's strategic goal of strengthening health care; (2) identifies and communicates to stakeholders any gaps between existing programs and future health care workforce needs identified in the Health Resources and Services Administration's workforce projection reports; (3) identifies actions needed to address identified gaps; and (4) identifies and communicates to Congress the legislative authority, if any, the Department needs to implement the identified actions.

Agency: Department of Health and Human Services
Status: Open

Comments: In December 2016, HHS indicated that the agency had not yet taken steps to implement a comprehensive workforce planning effort. Officials said that for the FY2018 cycle, HHS had planned to expand its group developing legislative proposals to include budget issues and gaps that warrant attention. While it did not do so during that cycle, officials indicated that they would recommend this broader approach to workforce planning for future budget and legislative cycles. In an update presented in HHS's FY2021 budget justification, HHS did not address efforts to develop a comprehensive and coordinated planning approach to guide HHS's health care workforce development programs. Instead, it described its current legislative and budget development effort and proposal to restructure CMS Graduate Medical Education (GME) programs into a discretionary grant program. It noted that such a restructuring would allow the Department to set expectations for program performance in CMS GME and allow the kind of tracking HRSA has been able to implement in the Children's Hospital GME program and its Teaching Hospital GME program. It noted that Congress had not responded to this request. However, this recommendation stands on its own and is separate from any legislative efforts to modify how federal GME funds are distributed. Whether or not legislation is enacted to implement a consolidated federal GME grant program, HHS should take action to develop a comprehensive and coordinated planning approach. Such action is important for HHS to assure that federal programs fully meet workforce needs. Further, the CARES Act of 2020 requires HHS to develop a comprehensive and coordinated strategic plan for HHS health workforce programs. We will be monitoring HHS's implementation of this requirement to determine if it satisfies the intent of this recommendation.

Recommendation: To ensure that the Family Caregiver Program is able to meet caregivers' demand for its services, the Secretary of the Department of Veterans Affairs should expedite the process for identifying and implementing an IT system that fully supports the program and will enable VHA program officials to comprehensively monitor the program's workload, including data on the status of applications, appeals, home visits, and the use of other support services, such as respite care.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with our recommendation and the Veterans Health Administration (VHA) and the Office of Information and Technology (OIT) have been working jointly on projects since 2015 to improve and replace the IT system for the Family Caregiver Program. However, two of these projects were terminated without delivering viable software improvements or a replacement system. According to two independent assessments, these prior efforts lacked both effective leadership and implementation of the processes needed for requirements management. In March 2019, VA began a third project, the Caregiver Record Management Application (CARMA), in which OIT and VHA began to acquire and implement a commercial product to replace the program's existing IT system. In February 2020, VA reported that to support the administrative needs of the Family Caregiver Program it had transitioned from its previous IT system to CARMA, its new IT system, in two stages: 1) In October 2019, VA deployed an initial release of CARMA for data entry of veterans and caregivers newly participating in the program, and 2) On December 2, 2019 the transition of existing veterans and caregivers to CARMA occurred. VA also reported in February 2020 that further enhancements and improvements to CARMA would be released over the coming months. However, the department has not yet fully committed to a date by which it will certify that CARMA fully supports the program. As of July 2020, this recommendation remains open pending further updates.

Recommendation: The Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to use data from the IT system, once implemented, as well as other relevant data to formally reassess how key aspects of the program are structured and to identify and implement modifications as needed to ensure that the program is functioning as envisioned so that caregivers can receive the services they need in a timely manner.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. VA transitioned in late 2019 to a new IT system, the Caregiver Record Management Application (CARMA). However, the Department has not yet certified the readiness of CARMA to fully support the needs of the Program of Comprehensive Assistance for Family Caregivers (Family Caregiver Program). Prior to the transition to CARMA, VA had developed manual processes to obtain and monitor key data points, allowing it to reassess policies and procedures for the Family Caregiver Program. In its September 2019 update, VA reported that it anticipates being able to certify the IT system when proposed regulatory changes to enable the expansion of the Family Caregiver Program are finalized and the necessary changes which have an impact on IT are implemented. VA also reported that following certification, IT development will continue on IT requirements that do not directly impact VA's ability to expand the program, such as improving the program's ability to track and report on clinical appeals. As of July 2020, this recommendation remains open pending further updates on how VA plans to use data from the IT system to monitor and assess the program's performance.

Recommendation: To help ensure that DOD and Congress have visibility over the necessity of the Selective Service System to meeting DOD's needs, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to establish a process of periodically reevaluating DOD's requirements for the Selective Service System in light of changing threats, operating environments, and strategic guidance.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and said that it would establish a process to review the mission and requirements for the Selective Service System. The National Defense Authorization Act for Fiscal Year 2017 established the National Commission on Military, National and Public Service (i.e., the Commission) to, among other things, review the military selective service process. The Commission is to submit a report to the President and Congress no later than March 2020 with recommendations concerning the need for a military draft and means by which to foster a greater ethos of public service among American youth. Further, the Commission was directed to conduct hearings and meetings open to the public in various locations throughout the country to provide maximum opportunity for public comment and participation in order to help develop its recommendations. In January 2019, the Commission released an Interim Report. The Interim Report shared what the Commission learned throughout its first year, explored options the Commission is considering to increase service participation among all Americans, and outlined issues involved in the Commission's review of the military selective service process. In March 2020, the Commission issued its final report, and it recommended that (1) the Congress require the Secretary of Defense to update the personnel requirements and timeline for obtaining draft inductees in the event of an emergency requiring mass mobilization and (2) the President direct the Secretary of Defense to include in future Quadrennial Defense Reviews and National Defense Strategies a section on the state of the Selective Service System and the ability of the United States to rapidly mobilize personnel in the event of an emergency. The Commission's report reinforced our recommendation; however, until DOD takes action to respond to our recommendation to take actions to establish a process to periodically review the mission and requirements of the Selective Service System, this recommendation should be left open.

Recommendation: As HHS implements its current and forthcoming efforts to make transparent price information available to consumers, HHS should determine the feasibility of making estimates of complete costs of health care services available to consumers through any of these efforts.

Agency: Department of Health and Human Services
Status: Open

Comments: In May 2013, CMS released average inpatient hospital charge information for more than 3,000 hospitals that receive Medicare Inpatient Prospective Payment System payments for the 100 most frequently billed discharges using DRGs from FY2011 and corresponding average Medicare payments. Shortly thereafter CMS also released outpatient charges. In April 2014, CMS also released data on payments to physicians under Medicare part B. This represents an effort to provide price transparency, although these are not complete cost estimates according to our definition in this report. As of September 2015, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: As HHS implements its current and forthcoming efforts to make transparent price information available to consumers, HHS should determine, as appropriate, the next steps for making estimates of complete costs of health care services available to consumers.

Agency: Department of Health and Human Services
Status: Open

Comments: As of September 2015, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: To better understand the extent to which deployed DOD civilian employees have access to needed medical care, as appropriate, the Secretary of Defense should direct the Combatant Commander of U.S. Central Command to clarify the level of care that deployed DOD civilian employees can expect in theater, including their eligibility for routine care.

Agency: Department of Defense
Status: Open

Comments: DOD has not implemented this recommendation. In July 2019, DOD officials responsible for policy concerning deployed civilians clarified that DOD policy states deployed civilians are eligible for medical care at the same level and scope as military personnel. However, as of November 2019 they were unable to confirm whether policy in U.S. Central Command reflects this requirement. .

Recommendation: To better account for physicians practicing in underserved areas through the use of J-1 visa waivers, the Secretary of Health and Human Services should collect and maintain data on waiver physicians--including information on their numbers, practice locations, and practice specialties--and use this information when identifying areas experiencing physician shortages and placing physicians in these areas.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurred with our recommendation, commenting that the department's goal was to assure that the limited resources of the J-1 visa waiver program and other programs addressing areas and populations with limited access to health care professionals are targeted most effectively. In 2013, HHS indicated that it was considering the best approach to collect information to identify J-1 visa physicians practicing in underserved areas. As of February 2018, however, HHS reported that it does not have the capacity to track physicians practicing in underserved areas through the use of J-1 visa waivers, citing reasons such as the number of federal entities and states involved in the process. While we recognize that collecting and maintaining these data requires coordination with other agencies, we continue to believe that without data on waiver physicians, HHS--the federal agency with primary responsibility for addressing physician shortages--will lack the information needed to consider waiver physicians working in underserved areas when placing providers in these areas under other programs. As of August 2019, HHS officials have not informed us of actions taken to implement this recommendation. We are leaving this recommendation open until the department collects and maintains data on waiver physicians and considers those physicians in its efforts to address physician shortages.