Defense Health: Coordinating Authority Needed for Psychological Health and Traumatic Brain Injury Activities [Reissued on January 27, 2012]
Highlights
What GAO Found
From fiscal year 2007 through fiscal year 2010, DOD activities for the treatment and research of PH and TBI received more than $2.7 billion. In fiscal year 2007, funding for these activities totaled $900 million; in fiscal year 2008, it was $573.8 million; in fiscal year 2009, $395 million; and in fiscal year 2010, $838.6 million. GAO found, however, that the reports DOD provided to Congress on these activities did not include expenditures, as required by law, and that the obligations data they contained were unreliable. Governmentwide policies call for agencies to have effective internal controls to assure accurate reporting of obligations and expenditures. However, the Office of the Assistant Secretary of Defense for Health Affairs has not developed quality control mechanisms to help ensure that data on PH and TBI activities are complete and accurate. Further, although DOD listed patient care among reported costs, it did not specify what those costs included, making it difficult for decisionmakers and Congress to fully understand the costs.
No one organization coordinates DOD’s PH and TBI activities. The National Defense Authorization Act for Fiscal Year 2008 directed the Secretary of Defense to establish a Center for PTSD and a Center for TBI to, among other things, implement DOD’s comprehensive plans for these issues, disseminate best practices, provide guidance, and conduct research. Subsequently, a Senior Oversight Committee established by the Secretaries of Defense and Veterans Affairs reported in its plan to Congress that DOD had created a single Defense Center of Excellence for PH and TBI (DCOE) to lead efforts in practice standards, training, outreach, research, and direct care. The Committee tasked DCOE with acting as an information clearinghouse that would allow servicemembers and their families to navigate the system of care. In its own plan, DCOE stated that it would serve as a coordinating authority for DOD's PH and TBI issues and perform a gap analysis to identify needed programming. GAO found, however, as it had in prior reports, that DCOE’s strategic plan did not reflect a clear mission focusing the organization on its statutory responsibilities. Instead, those responsibilities are dispersed among the TRICARE Management Activity, the Army Medical Research and Materiel Command, and others. While the Office of the Assistant Secretary of Defense for Health Affairs has broad oversight for all of DOD’s medical missions, its global role prevents it from focusing on PH and TBI activities specifically. As a result, no single organization is devoted to ensuring that accurate and timely data are available on DOD’s PH and TBI activities or coordinating these activities. GAO, in conducting this review, had to obtain information from several different sources to compile a comprehensive list of DOD's PH and TBI activities. This finding was echoed in a recent RAND report that also noted that no single source in DOD tracked its PH and TBI programs or had appropriate resources to direct servicemembers to the full array of programs available. Without an entity to coordinate these activities, DOD will remain hampered in its efforts to ensure that resources are used effectively to meet goals, and Congress will be limited in its ability to obtain reliable information to guide decisionmaking.
Why GAO Did This Study
Post-traumatic stress disorder (PTSD), which falls into the broader field of psychological health (PH), and traumatic brain injury (TBI) are recognized as the signature wounds of the wars in Afghanistan and Iraq. In two reports issued in 2011 (GAO-11-219 and GAO-11-611 ), GAO cited numerous management weaknesses at the Defense Center of Excellence for PH and TBI (DCOE). For the present report, GAO reviewed (1) funding for DOD's PH and TBI activities in fiscal years 2007 through 2010 and the accuracy of its reporting on these activities to Congress and (2) DOD's ability to coordinate its PH and TBI activities to help ensure that funds are used to support programs of the most benefit to service- members. GAO interviewed DOD officials, reviewed legislation and DOD’s annual reports, and obtained relevant documentation.
Reissued on January 27, 2012
Recommendations
GAO recommends that DOD direct the Assistant Secretary of Defense for Health Affairs to (1) include expenditure data in annual reports to Congress, as required; (2) establish quality control mechanisms on PH and TBI data; (3) if patient care costs are provided in future annual reports, specify what they include; and (4) revisit DCOE’s role as DOD’s coordinating authority for issues concerning PH and TBI, as stated in DCOE’s campaign plan, and determine whether DCOE or another organization should perform this function. In written comments on a draft of this report, DOD concurred with all four recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Defense | To increase visibility over how DOD is spending appropriated funds to address PH and TBI conditions, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to include expenditures for PH and TBI activities in annual reports to Congress as directed by Section 1634 of the National Defense Authorization Act for Fiscal Year 2008. |
In commenting on our findings and recommendation, DOD stated that it would include available expenditure data in the next annual report. In the two (2) Reports to Congress (2012, 2013) subsequent to report issuance (01/2012), DOD did report on expenditures for PH and TBI activities as directed by Section 1634 of the National Defense Authorization Act for Fiscal Year 2008 and GAO's recommendation in GAO-12-154.
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| Department of Defense | To increase visibility over how DOD is spending appropriated funds to address PH and TBI conditions, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to develop, maintain, and coordinate quality control mechanisms that help ensure that the obligation and expenditure data they report on PH and TBI projects and research are complete and accurate. |
In April 2016, the Defense Health Agency (DHA) published Technical Manual 7220.01 "Defense Health Program (DHP) Common Cost Accounting Structure (CCAS) Guidance (TAG)". The Common Cost Accounting Structure (CCAS) Technical Accounting Guidance (TAG) establishes common structure and accounting practices for the budgetary and cost accounting fields. According to DHA, the mapping effort is critical in helping components to report their program costs in a standardized way based on existing fields within their system. One TAG enclosure outlines the use of Agency Initiative Codes to track specific high interest initiatives across the Military Health System, specifically naming Psychological Health and Traumatic Brain Injury as examples. According to the Technical Manual, an Agency Initiative Code will provide decision-makers with a uniform, reliable way to collate all of the information required for management of these types of programs and initiatives at the enterprise level. A common cost accounting structure indeed defines what should be done and indeed enables DHA to consistently account for obligations and expenditures. However, a common cost accounting structure does not ensure that it will be successful in doing so or that the obligations and expenditure data will be complete and accurate. Specifically, the TAG does not detail what quality control steps they plan to take or are taking to prevent and detect errors in the use of the new common cost accounting structure. Relevant quality control mechanisms would include leadership, training/professional development, supervision and performance evaluation, monitoring, including data reconciliations and audits; as of September 2016, DHA has not yet taken these steps and only has plans to do so in the near future.
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| Department of Defense | To increase visibility over how DOD is spending appropriated funds to address PH and TBI conditions, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to, if patient costs are provided in future annual reports, clearly show what is included and not included for all patient costs. |
In commenting on our findings and recommendation, DOD stated that the provision of patient data was intended to be informative, but since including this information may have been confusing for the reader, DOD would omit this information in future reports. In the two Reports to Congress (2012, 2013) subsequent to report issuance (01/2012), DOD did not report on patient costs.
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| Department of Defense | To increase visibility over how DOD is spending appropriated funds to address PH and TBI conditions, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to revisit DCOE's role as DOD's coordinating authority for issues concerning PH and TBI, as stated in its own plan, and determine whether it or another organization should perform this function. |
After GAO issued its report on January 27, 2012, the 05/25/12 HAC Report 112-493, dated May 25, 2012 cited GAO-12-154 findings concerning the need to clarify which organization should serve as the department's coordinating authority on PH and TBI matters, among other things. The Committee stated it was "dismayed at the GAO's recent findings and encourage[d] the Assistant Secretary of Defense (Health Affairs) to follow the GAO's recommendations. On June 4, 2012, SASC Report 112-173 (section 733) also cited GAO-12-154 findings concerning, among other things, the "lack of a single organization devoted to ensuring that accurate and timely data are available on DOD's psychological health and traumatic brain injury activities or coordinating these activities.'" Accordingly, the committee recommended a provision that would require the DOD to develop and report to the Senate and House Committees on Armed Services a plan to streamline DOD programs that address psychological health and traumatic brain injury. As of March 2013, DOD indicated that Department of Defense Directive 6000.17 E, "Executive Agent (EA) for the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE)", transferred control and operational support of the DCoE from the TRICARE Management Activity (TMA) to the Secretary of the Army. While DOD has indeed transferred DCOE to the Department of the Army per DOD Directive 6000.17 E and the recently updated DCoE Concept of Operations specifies its roles and responsibilities, the recommendation remains open as neither document clearly identifies DCOE as the coordinating authority for PH and TBI issues in DOD.
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