Recommendation: To facilitate DOD's oversight of the military services' S&I pay programs, and to fully ensure the effectiveness of these programs, the Secretary of Defense should direct the Under Secretary of Defense (Comptroller), in coordination with the military services, to explore cost-effective approaches to collect and report S&I pay program data for the Reserve Components.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. In its initial response, DOD noted that it will maintain its focus on the recruiting and retention pays for both the active and reserve components, and will continue to work with the Reserve Components to strengthen the collection of the remaining special and incentive pays. As of November 2019, DOD had not taken action on this recommendation.

Recommendation: To facilitate DOD's oversight of the military services' S&I pay programs, and to fully ensure the effectiveness of these programs, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness, in coordination with the military services, to review whether S&I pay programs have incorporated key principles of effective human capital management and used resources efficiently, and prioritize and complete the establishment of measures for the efficient use of resources.

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. In DOD's initial response, it stated that DOD does use key principles of effective human capital management, and although not articulated as GAO's principles, DOD's and GAO's principles share common goals and results. In addition, DOD stated that it will support the opportunity to review and improve upon the principles and methods to assess the efficiency of its S&I pay programs, and, where appropriate, will incorporate these principles in future DOD policy issuances and updates. In May 2018, DOD stated that it believed it was in compliance with this recommendation and that the action was complete. DOD stated that this assessment was based on our finding that most of the Department's S&I pay programs either met or partially met the key principles of effective human capital management. But our finding was on select pay programs. Further, DOD's response did not document what actions the Department has taken to ensure all programs fully meet the key principles. As of November 2019 DOD had not taken action on this recommendation. We continue to believe that fully implementing the key principles of effective human capital management that we identified would help DOD and the services to ensure that S&I pay programs are effectively designed and that resources are optimized for the greatest return on investment.

Recommendation: To facilitate DOD's oversight of the military services' S&I pay programs, and to fully ensure the effectiveness of these programs, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness, in coordination with the military services, to routinely assess the impact of non-monetary incentive approaches on retention behavior and on the necessary levels of S&I pays.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2017, DOD had submitted a proposal to conduct a study focused on aviation officers that will examine the military services' methodologies used to accomplish their retention goals to determine the primary reasons aviation officers remain or leave the service and the degree to which these reasons affect their retention decisions. According to DOD officials, a portion of the study will consider the interaction between monetary and non-monetary incentives such as duty assignments, flying opportunities, reduced administrative burdens, and quality of life. In May 2018, DOD stated that the Military Departments continue to utilize non-monetary incentives as their first approach to access and retain quality servicemembers. DOD added that these incentives consist of choice of career path, duty assignment, selective military training, educational benefits, as well as the career intermission program. DOD noted that the Army's Career Satisfaction Program is just one example of using non-monetary pay incentives to improve retention. According to DOD, this program increases the retention of Army officers at no additional cost to the Army by offering academy cadets and senior ROTC cadets the choice of occupational specialty and assignment location upon commissioning in exchange for extending their active duty service obligation for an additional 3 years. DOD also stated that the Navy currently uses both monetary and non-monetary incentives to retain its surface warfare officer (SWO) community to ensure it retains adequate numbers of officers to fill critical SWO Department Head positions in the rank of Lieutenant and Lieutenant Commander. The Department concluded that it believes the recommendation is closed, as it has offered and continues to offer non-monetary incentives as part of its S&l pay program, and continues to encourage the use of non-monetary incentives as an alternative to cash incentives. While the programs DOD mentioned in its response demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made. As of November 2019, DOD had not taken additional actions on this recommendation.

Recommendation: To facilitate DOD's oversight of the military services' S&I pay programs, and to fully ensure the effectiveness of these programs, the Secretary of Defense should direct the Secretaries of the Military Departments to develop approaches to directly target Selective Reenlistment Bonuses to cybersecurity skill sets.

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. In DOD's initial response, it stated that the services are responsible for developing their personnel requirements in order to meet individual service needs and that it has provided the services with the necessary staffing tools to recruit and retain servicemembers in the cybersecurity skill sets. DOD also noted that it is crucial for the services to retain their flexibility to utilize these pays and benefits to address service-specific shortfalls within their cybersecurity workforce and noted that it will assist the services in growing and maintaining their cybersecurity workforce through existing and future DOD policies. In August 2018, DOD reiterated that the services have responsibility for developing their manpower requirements and employing the necessary manpower tools, such as bonuses and incentives, to achieve their goals, including those for the cybersecurity workforce. DOD added that the current suite of special and incentive pays already provides the services the necessary authorities and flexibilities to access and retain servicemembers in their cybersecurity communities. DOD concluded that it believed their actions to address this recommendation were complete. We recognize that the services are responsible for their specific personnel requirements and that flexibility is important. However, as noted in our report, each military service has assigned cybersecurity personnel to military occupational specialties that include other types of personnel skill sets, such as intelligence or information technology. As a result, because the services offer SRBs by military occupational specialty, the services may award SRBs to specialties that include non-cybersecurity personnel for whom the SRB is unneeded. Therefore, we continue to believe that there are benefits to developing approaches to target cybersecurity personnel in non-designated cybersecurity fields and that this recommendation should remain open. As of November 2019, DOD had not taken additional actions on this recommendation.

Recommendation: To determine the extent to which Medicare payments are aligned with costs for specific types of dialysis treatment and training, the Administrator of CMS should take steps to improve the reliability of the cost report data for treatment and training associated with specific types of dialysis.

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: As of February 2020, CMS has not implemented this recommendation. HHS agreed with this recommendation and stated in February 2020 that CMS was exploring ways to clarify the cost report instructions in an effort to improve the accuracy of the information submitted. We will update the status of this recommendation when we receive additional information.

Recommendation: To ensure that patients with chronic kidney disease receive objective and timely education related to this condition, the Administrator of CMS should examine the Kidney Disease Education benefit and, if appropriate, seek legislation to revise the categories of providers and patients eligible for the benefit.

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: As of February 2020, CMS has not implemented this recommendation. HHS did not agree with this recommendation and stated in June 2016 that CMS continuously works to pay appropriately for ESRD services and must prioritize its activities to improve care for dialysis patients. While we acknowledge the need for CMS to prioritize its activities to improve dialysis care, it is important for CMS to help ensure that Medicare patients with chronic kidney disease understand their condition, how to manage it, and the implications of the various treatment options available, particularly given the central role of patient choice in dialysis care. The limited use of the Kidney Disease Education benefit that we noted in our report suggests that it may be difficult for Medicare patients to receive this education and underscores the need for CMS to examine and potentially revise the benefit. We will update the status of this recommendation when we receive additional information.

Recommendation: To ensure that up-to-date data are available on the road damages imposed by all vehicles types compared with the revenues each contributes to the Highway Trust Fund, the Secretary of Transportation should direct the FHWA Administrator to revise and publish the agency's Highway Cost Allocation Study and update it periodically as warranted.

Agency: Department of Transportation
Status: Open

Comments: As of April 2020, FHWA stated it does not plan to revise and publish the agency's Highway Cost Allocation Study because of the cost of doing so and the uncertainty about whether and how it would be used. GAO continues to believe that up to date information on the cost of road damage imposed by all vehicle types compared with the revenues contributed by those vehicles to the Highway Trust Fund is needed to help determine whether user fees are sufficient to cover damage costs. Moreover, Congress and the administration need to agree on a long-term sustainable plan for balancing spending from and revenues to the Highway Trust Fund and, for this reason, funding surface transportation is on GAO's High Risk List. GAO will continue to monitor any efforts by DOT and FHWA to respond to our recommendation.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to coordinate with the services on conducting research, as appropriate, to determine optimal bonus amounts.

Agency: Department of Defense
Status: Open

Comments: In a July 2012 report, the USD (P&R) stated that it continued to believe that a study to determine optimal bonus amounts would be beneficial. As of September 2015, DOD was working with the RAND Corporation to develop a model to analyze the impact of adjusting bonuses and special pays for certain personnel communities. According to officials at USD (P&R) the goal of this effort was to provide the services with a tool that can be used to set bonuses and special pays more efficiently. The officials added that models have been developed for officers in the aviation community, and are currently being developed for officers in the healthcare and special operations communities. OSD officials reported in February 2017 that the study by RAND covering all bonuses and special pays had still not been issued. RAND did issue a study, but it covered only mental health care officers. As of November 2019, DOD has not taken any further action on this recommendation.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness, as the consolidation of the special and incentive pay programs is completed over the next 7 years and the instructions directing the services on how to administer the new programs are revised, to monitor the implementation of this consolidation to determine whether it is in fact resulting in greater flexibility and more precise targeting of resources and what impact the consolidation is having on DOD's budget.

Agency: Department of Defense
Status: Open

Comments: In a July 2012 report, the USD (P&R) stated that it was continuing to consolidate special and incentive pay authorities. However, because this consolidation was not yet complete, it has not yet determined whether this consolidation has resulted in greater flexibility, as GAO recommended. In June 2013, OSD reported that OSD was about halfway through with its effort to consolidate special pay authorities, and in September 2015 USD (P&R) officials stated that this effort is continuing. The officials added that, while the Department is tracking the impact of the consolidation on the cost of special and incentive pays, it had not assessed whether the consolidation had resulted in greater flexibility. OSD officials reported that in November 2019 it had still not completed a study of whether the consolidation had resulted in greater flexibility.

Recommendation: In light of the need for accurate and complete information on children's access to health services under Medicaid and CHIP, the requirement that states report information to CMS on certain aspects of their Medicaid and CHIP programs, and problems with accuracy and completeness in this state reporting, the Administrator of CMS should work with states to identify additional improvements that could be made to the CMS 416 and CHIP annual reports, including options for reporting on the receipt of services separately for children in managed care and fee-for-service delivery models, while minimizing reporting burden, and for capturing information on the CMS 416 relating to children's receipt of treatment services for which they are referred.

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: In August 2019, CMS stated that the agency's long-term plan is to use the Transformed Medicaid Statistical Information System (T-MSIS) to analyze information on children's receipt of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. As of June 2020, CMS had developed a new CMS-416 reporting form that gives states the option of having CMS calculate the measures for the report using T-MSIS. CMS stated that it intends to implement this option for states for fiscal year 2020 CMS-416 reports, which are due in April 2021. As of August 2020, the new CMS-416 form was undergoing Paperwork Reduction Act review. CMS is also exploring using T-MSIS to generate the Core Set of Children's Health Care Quality Measures for Medicaid and CHIP, some of which are included in the CHIP annual report. As of June 2020, CMS had begun a pilot test to generate five of the Core Set measures using 2018 T-MSIS data. GAO considers this recommendation open and will continue to monitor CMS's progress towards its long-term goal of using T-MSIS to monitor children's receipt of EPSDT services.