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: As MHS governing bodies conduct their recurring reviews of quality measures selected for MHS's Core Dashboard and Purchased Care Dashboards, the Assistant Secretary of Defense for Health Affairs should direct those bodies to prioritize, as appropriate, the selection of measures that apply to both direct and purchased care at the provider level and that expand the range of quality measure types and medical conditions that are assessed. (Recommendation 1)

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

Comments: As of January 2020, DOD officials described proposed actions to address key elements of our recommendation. Specifically, DOD officials described compiling a comprehensive library of existing inpatient and outpatient quality measures for both direct and purchased care; categorizing those measures by type and medical condition; and identifying 8 measures that are common across direct and purchased care. DOD stated it is considering expanding those 8 common measures to 12 measures. The new measures would cover three cancer screening measures and an additional inpatient satisfaction measure. However, DOD officials noted these 12 measures are not reported at the provider level for purchased care given current contract reporting requirements and would require contract modifications. DOD officials also said they are participating in an interagency partnership to use a common set of quality measures across federal programs, including under the Department of Veterans Affairs. Once those quality measures are determined, DOD may expand the range of quality measures common across direct and purchased care to be consistent with other federal programs. We will keep this recommendation open until DOD provides additional information on actions taken to select and expand quality measures across direct and purchased care.

Recommendation: The Assistant Secretary of Defense for Health Affairs should establish, as appropriate, performance standards related to the Purchased Care Dashboard measures that are consistent with the MHS's performance standards for direct care; ensure they are applied to individual purchased care providers; and take steps, such as amending its managed care support contracts, if necessary, to require corrective actions to be taken when providers do not meet those standards. (Recommendation 2)

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

Comments: As of January 2020, DOD officials said that once a common set of quality measures is adopted to the extent possible across direct and purchased care (as discussed in Recommendation 1), DOD plans to establish consistent performance standards applied to individual providers and plans to develop processes to issue corrective actions for individual direct and purchased care providers who do not consistently meet established standards. We will update this recommendation as DOD provides progress updates on the implementation of these plans.

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 better assess and address the full extent of improper payments in the TRICARE program, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to implement a more comprehensive TRICARE improper payment measurement methodology that includes medical record reviews, as done in other parts of its existing postpayment claims review programs.

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: The Department of Defense (DOD) concurred with our recommendation. As of November 2019, the DOD's Defense Health Agency (DHA) has taken some action to incorporate medical record reviews in its improper payment estimate, as GAO recommended in February 2015. In June 2017, DHA awarded a contract for TRICARE claims review services which, according to DHA officials, will allow the agency to implement a more comprehensive improper payment measurement methodology using retrospective medical records reviews. As of November 2019, the agency reported to Congress that its managed care support contracts now included medical record reviews. It also expected to include payment error results from medical record reviews in its improper payment calculation for fiscal year 2020. DOD also planned to report the effect of medical record reviews on its improper payment rate in a report to Congress in March 2020. Once DHA incorporates medical record reviews in its improper payment rate calculation methodology, GAO will be able to close this recommendation.

Recommendation: To better assess and address the full extent of improper payments in the TRICARE program, and once a more comprehensive improper payment methodology is implemented, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to develop more robust corrective action plans that address underlying causes of improper payments, as determined by the medical record reviews.

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: The Department of Defense concurred with our recommendation. As of November 2019, the Department of Defense's Defense Health Agency (DHA) has taken steps to implement a more comprehensive TRICARE improper payment measurement methodology. Until the department fully implements the new methodology and identifies the underlying causes of improper payments, the full extent of improper payments in the TRICARE program will likely not be identified and addressed. As of November 2019, the DHA has not yet fully implemented a more comprehensive measurement methodology, and has, therefore, not developed more robust corrective action plans.

Recommendation: To eliminate unnecessary program duplication and to achieve increased efficiencies and potential savings within the integrated MHS, Congress should terminate the Secretary of Defense's authority to contract with the USFHP designated providers in a manner consistent with a reasonable transition of affected USFHP enrollees into TRICARE's regional managed care program or other health care programs, as appropriate.

Agency: Congress
Status: Open

Comments: As of April 2017, no actions have been taken.

Recommendation: To address weaknesses in DCOE's strategic plan, the Secretary of Defense, through the Director of TMA, should direct the DCOE director to revisit and revise as necessary the organization's goals for completing statutorily required responsibilities.

Agency: Department of Defense
Status: Open

Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.

Recommendation: To address weaknesses in DCOE's strategic plan, the Secretary of Defense, through the Director of TMA, should direct the DCOE director to require the directorates to align their day-to-day activities to support DCOE's mission and goals.

Agency: Department of Defense
Status: Open

Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.

Recommendation: To address weaknesses in DCOE's strategic plan, the Secretary of Defense, through the Director of TMA, should direct the DCOE director to improve the performance measures in the plan to enable DCOE to determine if achievement of each measure fully supports attainment of its associated goal.

Agency: Department of Defense
Status: Open

Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.

Recommendation: To ensure that DCOE obligations are properly classified and recorded in accordance with OMB guidance, the Secretary of Defense, through the Office of the Assistant Secretary of Defense (Health Affairs) (ASD(HA)), should direct TMA to develop written procedures with detailed steps to be performed for ensuring proper classification and recording of obligations in TMA's financial management systems.

Agency: Department of Defense
Status: Open

Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.

Recommendation: To ensure that DCOE obligations are properly classified and recorded in accordance with OMB guidance, the Secretary of Defense, through the ASD(HA), should direct TMA to assign responsibility for updating and maintaining procedural guidance and systems codes to assure consistency with annual OMB guidance.

Agency: Department of Defense
Status: Open

Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. 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 help DOD obtain reasonable assurance that all active and Reserve component servicemembers to whom the PDHRA requirement applies are provided the opportunity to have their health concerns identified, the Assistant Secretary of Defense for Health Affairs and the military services should take steps to ensure that PDHRA questionnaires are included in DOD's central repository for each of these servicemembers.

Agency: Department of Defense
Status: Open

Comments: In its comments to this report, the Department of Defense (DOD) concurred with this recommendation. On October 2009, DOD's Force Health Protection and Response Office sent a memo to each of the military service Surgeons General emphasizing the need for the post-deployment health reassessment (PDHRA) to be offered to all service members who are eligible to complete the assessment. In 2010, DOD's noted that the services would work with the Armed Forces Health Surveillance Center (AFHSC) repository to ensure PDHRAs are submitted correctly, without transmission errors. DOD's 2011 case records showed that the Air Force and Army had developed data verification processes to ensure that AFHSC received PDHRAs. Further, the Defense Medical Data Center (DMDC) had planed to create a file consisting of the date of deployment for deployed personnel, and that the file would be available to the services in order to match DMDC with data from each of the service-specific systems, in accordance to requirements. In September 2011, although DMDC and the services had agreed to match rosters of deployed service members, there were still inconsistencies in deployment dates. In March 2012, DOD was still verifying data inconsistencies which, until resolved, leads to inaccurate reporting based on errors in the deployment dates. As of September 2019, DOD has not provided information or documentation to address this recommendation.