Recommendation: The Under Secretary for Health should fully define in VHA policy the oversight roles and responsibilities related to ensuring facilities' adherence to disbursement agreement policies, including roles related to ReDPro and the role of VISNs. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should more clearly define in VHA policy the purposes of the periodic independent audits and the ReDPro checklist reviews—including differentiating their purposes from one another and ensuring that they do not unnecessarily overlap. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA and CBI modify the ReDPro checklist and associated guidance, to include ensuring that checklist items are clearly stated, relevant to the updated purpose of the ReDPro checklist, and not unnecessarily duplicative of items to be addressed by the periodic independent audits. The guidance should also include detailed instruction on what the compliance officers should review, and how they should determine the appropriate response for each checklist item. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA and CBI develop and provide additional ReDPro training for compliance officers, consistent with the updated checklist and guidance. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how ReDPro reviews should be conducted. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA implements a standardized independent audit tool that is consistent with the updated purpose of the periodic independent audits, and does not unnecessarily overlap with the ReDPro checklist. This could include modifying its existing recommended checklist, or developing a new tool. (Recommendation 5)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA develops guidance for periodic independent audits to assist the audit teams and facility management in understanding how audits are to be conducted. (Recommendation 6)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA develops substantive training for independent audit team members, consistent with the updated audit purpose, guidance, and tools. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how the independent audits should be conducted. (Recommendation 7)

Agency: Department of Veterans Affairs
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 HHS should coordinate with federal agencies, including VA, that fund GME training to identify information needed to evaluate the performance of federal programs that fund GME training, including the extent to which these programs are efficient and cost-effective and are meeting the nation's health care workforce needs. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open

Comments: In January 2020, HHS indicated that the agency had not yet taken steps to identify information needed to evaluate the performance of federal programs that fund GME training, including the extent to which these programs are efficient and cost-effective and are meeting the nation's health care workforce needs. HHS reiterated its comments on GAO's report, noting that the President's fiscal year 2020 budget for HHS proposed consolidating federal spending from Medicare, Medicaid, the Teaching Health Center Graduate Medical Education Program, and the Children's Hospitals Graduate Medical Education Payment Program into a single grant program for teaching hospitals. The President's fiscal year 2021 budget for HHS also included this proposal. It noted that such a restructuring would allow the Department to set expectations for program performance in Medicare and Medicaid GME programs 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. As GAO noted in its 2018 report, 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 identify information needed to evaluate the performance of federal programs that fund GME training. Such action is important for HHS to assure that federal programs fully meet workforce needs. However, HHS did not otherwise indicate whether it had coordinated with federal agencies that fund GME training. As of January 2020, this proposal had not been adopted.

Recommendation: The Secretary of HHS should coordinate with federal agencies to identify opportunities to improve the quality and consistency of the information collected within and across federal programs, and implement these improvements. (Recommendation 2)

Agency: Department of Health and Human Services
Status: Open

Comments: In January 2020, HHS indicated that the agency had not yet taken steps to identify opportunities to improve the quality and consistency of the information collected within and across federal programs, and implement these improvements. HHS reiterated its comments on GAO's report, noting that the President's fiscal year 2020 budget for HHS proposed consolidating federal spending from Medicare, Medicaid, the Teaching Health Center Graduate Medical Education Program, and the Children's Hospitals Graduate Medical Education Payment Program into a single grant program for teaching hospitals. The President's fiscal year 2021 budget for HHS also included this proposal. It noted that such a restructuring would allow the Department to set expectations for program performance in Medicare and Medicaid GME programs 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. As GAO noted in its 2018 report, 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 identify information needed to evaluate the performance of federal programs that fund GME training. Such action is important for HHS to assure that federal programs fully meet workforce needs. However, HHS did not otherwise indicate whether it had coordinated with federal agencies that fund GME training. As of February 2020, this proposal had not been adopted.

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: 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 help ensure that DOD has the necessary information to determine the extent to which cost savings result from any future consolidation of training within METC or the Education and Training Directorate, the Assistant Secretary of Defense for Health Affairs should direct the Director of the DHA to develop baseline cost information as part of its metrics to assess achievement of cost savings.

Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
Status: Open

Comments: DOD concurred with this recommendation. As of November 2019, DOD is engaged in actions to help address this recommendation. Specifically, METC is developing a strategic plan concerning its objectives and goals and is assessing further consolidation efforts, such as in its medical and dental labs programs. However, DOD has not yet addressed our concerns regarding the DHA's Education and Training Directorate. In its most recent report on DHA shared services, the Education and Training Directorate listed the same 2 product lines noted in our report. Therefore, DOD savings that continue to be attributed to this Directorate are not specifically the result of any consolidation of training within METC or the directorate overall as we had recommended. Until this is done, we suggest this recommendation remain open.

Recommendation: To help realize the reform effort's goal of achieving cost savings, the Assistant Secretary of Defense for Health Affairs should direct the Director of the DHA to conduct a fully developed business case analysis for the Education and Training Directorate's reform effort. In this analysis the Director should (1) identify the cost-related problem that it seeks to address by establishing the Education and Training Directorate, (2) explain how the processes it has identified will address the costrelated problem, and (3) conduct and document an analysis of benefits, costs, and risks.

Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
Status: Open

Comments: DOD concurred with this recommendation. As of November 2019, DOD has not taken steps to address this recommendation. In its most recent report on DHA shared services, the Education and Training Directorate listed the same 2 product lines noted in our report, which as we reported in 2014, overlap with the DHA's Contracting and Procurement and Information Technology shared services. For example, while cost savings for Modeling and Simulation are allocated to the Medical Education and Training Directorate, implementation costs are to be incurred by the Contracting and Procurement shared service. This recommendation will remain open until DOD either identifies common functions to consolidate within Medical Education and Training to achieve cost savings or develops a justification for the transfer of these functions from the military services to the DHA that is not premised on cost savings.