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 DHA, consistently collect complete and accurate information about the quality of available civilian health care in proximity to its MTFs (such as ratings from the Centers for Medicare and Medicaid Services and perceptions from MTF officials who regularly coordinate with civilian providers, among other means) and assess that information to inform recommendations for future MTF restructuring decisions. (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. In its response, the department described its planned implementation steps, such as publishing measures it may use for assessing available civilian health care. We will continue to monitor the status of the measures and any other actions the department takes to address the 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 DHA, consistently collect complete and accurate information about the extent to which current health care providers within the TRICARE networks meet access-to-care standards, and assess that information to inform recommendations on future MTF restructuring decisions. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. The department noted actions underway and planned to implement it, including a centralized appointment booking system and monitoring access to care as MTFs restructure. We will continue to monitor the status of this effort and any other actions the department takes to address the 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 DHA, consistently collect complete and accurate information about the extent to which non-network civilian health care providers that could be incorporated into the TRICARE network meet access-to-care standards in terms of drive time, and assess that information to inform recommendations on future MTF restructuring decisions. (Recommendation 3)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation, and described planned steps to implement it for future MTF restructuring decisions. We will continue to monitor actions the department takes to address the 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 DHA, conducts a sensitivity analysis of the relative cost-effectiveness of MTF-provided care compared to civilian-provided care under varying assumptions, and document that information for decision makers to inform recommendations on future MTF restructuring decisions. Varying conditions could include different types of health care services, reducing the cost of military personnel salaries, and increasing estimated MTF wRVUs and civilian reimbursement rates. (Recommendation 4)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. We will continue to monitor actions the department takes to address the 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 DHA, establishes clear roles and responsibilities for executing and monitoring transitions for MTFs identified for restructuring. (Recommendation 5)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and described actions underway and planned to implement it. We will continue to monitor actions the department takes to address the 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 DHA, defines measurable objectives for MTF restructuring transitions, establishes thresholds and goals for each objective, and applies them to evaluate progress and challenges. For example, measurable objectives, thresholds, and goals, should include an evaluation of medical providers' clinical readiness, civilian health care provider adequacy, and the cost-effectiveness of MTF and purchased care. (Recommendation 6)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and described actions underway and planned to implement it. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should direct DHA to ensure that MTFs' referral management center staff are trained to process and accurately document information in MHS Genesis about specialty care referrals, including the receipt of CLRs, the submission of referral results, and the closure of referrals. (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 direct DHA to ensure that MHS Genesis is configured to produce reports that accurately reflect the use and outcomes of specialty care referrals. (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 coordination with Director of the DHA and the Surgeons General of the military departments, define and analyze the 16 operational readiness and installation-specific medical functions currently excluded from transfer to the DHA to determine whether opportunities exist to reduce or better manage duplicative functions and improve efficiencies in the administration of the MTFs. (Recommendation 1)

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: DOD concurred with this recommendation. According to responses provided by DOD officials in December 2019, the department provided guidance on the division of the 16 operational readiness and installation-specific medical functions in a March 2019 memorandum from the Office of the Under Secretary of Defense for Personnel and Readiness. However, further detail is needed regarding what analysis DOD completed to assess the 16 functions for duplication.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with DHA Assistant Director for Health Care Administration and the Secretaries of the military departments, validate headquarters-level personnel requirements to determine that they are established at the minimum levels necessary--per DOD guidance--to accomplish missions and achieve objectives before transferring authority, direction, and control of the MTFs to the DHA for the third phase. (Recommendation 2)

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: DOD concurred with this recommendation. In December 2019, DOD officials stated that DOD conducted a review of the DHA personnel requirements and that the military departments also conducted reviews. DOD officials also stated that DOD will continue to evaluate the mix of contractors, military, and civilian employees during and after the transition. However, the review of DHA personnel requirements DOD officials referenced in their December 2019 responses, as GAO previously reported in GAO-19-53, did not validate personnel requirements. Further information is needed regarding what steps DOD is taking to validate headquarters-level personnel requirements.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with DHA Assistant Director for Health Care Administration and the Secretaries of the military departments, conduct a comprehensive review to identify the least costly mix--per DOD guidance--of military, civilian, and contractors needed to meet validated requirements--that is, to perform the functions identified at the DHA headquarters and intermediate management organizations and at the military departments' headquarters and intermediate commands. Additionally, this comprehensive review should be completed before transferring authority, direction, and control of the MTFs to the DHA for the third phase. (Recommendation 3)

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: DOD concurred with this recommendation. In December 2019, DOD officials stated that through the review of the budget development process, DOD transferred 1,900 personnel to the military departments for the management of their respective readiness missions. Further, DOD officials mentioned a 2018 report concerning a review of DHA personnel requirements. As reported in GAO-19-53, the report on DHA personnel requirements was specific to DHA and did not include information regarding the military departments' headquarters and intermediate commands. Further information is needed to determine whether DOD's efforts included a comprehensive review that considers the least costly mix--per DOD guidance--of military, civilian, and contractor personnel.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to incorporate medical screening questions specific to gambling disorder as part of a systematic screening process across DOD, such as DOD's annual Periodic Health Assessment, for behavioral and mental-health issues.

Agency: Department of Defense
Status: Open

Comments: DOD non-concurred with this recommendation. However, the FY 2019 National Defense Authorization Act mandated that DOD implement this recommendation. As of August 2019, DOD had modified the Health Related Behaviors Survey (HRBS) to include questions on gambling and DOD and the Services are in the process of updating the electronic Periodic Health Assessment (PHA) assessment forms to capture the gambling screening data required by the legislation. Once the PHA is updated to include the gambling screening data, we will be able to close this recommendation.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to update DOD Instruction 1010.04, Problematic Substance Use by DOD Personnel, to explicitly include gambling disorder as defined in the 2013 Diagnostic and Statistical Manual of Mental Disorders.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2019, DOD stated that this guidance is still in internal DOD coordination. Moreover, guidance related to gambling disorder screening, referral, and treatment needs to be coordinated with the Addictive Substance Misuse Advisory Committee (ASMAC) before issuance, which is anticipated to be July 2020.

Recommendation: The Secretary of Defense should direct the Secretary of the Army to update Army Regulation 600-85, The Army Substance Abuse Program, to explicitly include gambling disorder.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2019, the Army did not have any updates to provide on the status of this recommendation.

Recommendation: The Secretary of Defense should direct the Secretary of the Navy to update Naval Operations Instruction 5350.4D, Navy Alcohol and Drug Abuse Prevention and Control, to explicitly include gambling disorder.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2019, Navy officials stated that the draft Navy instruction was returned back to the Navy's Drug Detection and Deterrence Program Office to add language regarding the Secretary of the Navy's ban on hemp/CBD products that was announced this month. The Navy has added the language and pushed the instruction out to the main stakeholders for coordination. It is due back to the Director, Navy Staff no later than 30 August 2019 where it will go back into the queue for signature. Navy officials anticipate signature sometime later this fall.

Recommendation: The Commandant of the Coast Guard should update Commandant Instruction M6000.1F, Coast Guard Medical Manual, to classify gambling disorder as an addiction and not as an impulse control issue.

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The U.S. Coast Guard/DHS concurred with this recommendation. As of August 2019, the Coast Guard stated that updates to this manual are ongoing. According to Coast Guard officials, including gambling disorder in this manual is one of many significant updates the program is adjudicating for this manual and it's a lengthy clearance process. No timeline was provided for expected issuance.

Recommendation: To help ensure that the military services' requirements for physician credentialing and privileging are consistent across the MHS, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Surgeons General of the military services to establish a DOD-wide process to identify and address existing inconsistencies between DOD's and the military services' physician credentialing and privileging requirements, including those inconsistencies we identified in this report.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To help ensure that the military services' requirements for physician credentialing and privileging are consistent across the MHS, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Surgeons General of the military services to establish a DOD-wide process to coordinate all current and future efforts to revise physician credentialing and privileging requirements.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to coordinate individual MTFs' efforts to establish mechanisms to collect and analyze data to evaluate physician performance and support performance assessments.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to clarify requirements for how MTFs document follow-up on peer recommendations, including who is responsible for documenting follow-up and where that documentation should be filed.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to clarify requirements for the information that physicians need to provide in their curriculum vitae (CV) so that MTFs can identify unaccounted for periods in practice history, as well as how MTFs should document explanations of any unaccounted for periods.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to establish requirements for MTFs to document significant events that occur during the review of a credentials file, including which types of significant events should be documented, who is responsible for documenting significant events, and where that documentation should be filed.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to establish a process to ensure that relevant information from the DPDB is documented in the credentials file.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that MTFs are fully complying with DOD's and the military services' requirements for physician credentialing and privileging and implementing these requirements appropriately, the Secretary of Defense should direct the Surgeons General of the military services to establish and implement an oversight process to conduct reviews of a sample of credentials files to identify and address areas of noncompliance and incomplete documentation.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.