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entitled 'Military Personnel: Enhanced Collaboration and Process 
Improvements Needed for Determining Military Treatment Facility 
Medical Personnel Requirements' which was released on July 29, 2010. 

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Report to Congressional Committees: 

United States Government Accountability Office: 
GAO: 

July 2010: 

Military Personnel: 

Enhanced Collaboration and Process Improvements Needed for Determining 
Military Treatment Facility Medical Personnel Requirements: 

GAO-10-696: 

GAO Highlights: 

Highlights of GAO-10-696, a report to congressional committees. 

Why GAO Did This Study: 

Military medical personnel, who are essential to maintaining one of 
the largest and most complex health systems in the nation, are in 
great demand due to the need to treat injured or ill servicemembers, 
and advances in technology that require specialized personnel. To 
determine how well the Department of Defense (DOD) and the services 
are developing their medical and dental personnel requirements, GAO 
evaluated (1) the extent to which the services have incorporated cross-
service collaboration in their medical personnel requirement 
processes, and (2) the service-specific processes for determining 
their requirements for military and civilian medical personnel. To 
conduct this review, GAO evaluated manpower policies, analyzed the 
services’ requirements data and determination processes, and 
interviewed officials from the Office of the Secretary of Defense 
(OSD) and each of the services. 

What GAO Found: 

While DOD’s 2007 Military Health System Human Capital Strategic Plan 
emphasizes developing human capital solutions across the services to 
enable departmentwide decision making and analyses, the services’ 
collaborative planning efforts regarding requirements determination 
for medical personnel working in fixed military treatment facilities 
have been limited. In one effort to integrate operations, DOD is 
consolidating medical facilities in the Washington, D.C., area under a 
joint task force that calls for joint staffing of the military 
treatment facilities in the region. However, officials have faced 
challenges in developing the manpower requirements for the joint 
facilities due to the use of outdated planning assumptions. 
Separately, the Office of the Secretary of Defense (OSD) sponsored 
another joint medical effort to develop a cross-service medical 
manpower standard for mental health personnel. This standard is being 
used to determine the amount of personnel needed to meet common, day-
to-day psychological health needs of eligible beneficiaries across the 
services. However, to date, this standard is the only one of its kind, 
and OSD officials said that no other similar efforts currently exist. 
The services’ continued focus on separate medical personnel 
requirements processes may not be consistent with the DOD strategic plan
’s vision of a more integrated approach, and the services may have 
missed opportunities to collaborate and develop cross-service manpower 
standards for common medical capabilities that are shared across 
military treatment facilities. Sustained and committed leadership 
emphasis on developing more effective ways of doing business, such as 
the use of cross-service medical manpower standards, is key to 
successful, collaborative human capital strategic planning. 

To the extent that the services need to maintain separate processes, 
GAO also found that their requirements processes are not, in all 
cases, validated and verifiable, as DOD policy requires. Selected 
specialty modules in the Army’s model contain some outdated 
assumptions, such as the level of care currently being provided, and 
only a portion of the modules have been completely validated. While 
the Navy has employed an approach that uses current manning as a 
baseline and adjusts its requirements based on emerging needs or major 
changes to missions, the approach is not validated or verified as 
required by DOD guidance. The Air Force said it may not know its true 
medical requirements as the model it has relied on also is not 
currently validated or verified. Each of the services has recognized 
the need to have processes that can be validated and verified, and has 
taken steps to address these issues in recent years. However, without 
processes that are validated and verifiable, the services cannot be 
certain they are determining their medical personnel requirements in 
the most effective and efficient manner. Also, the services do not 
centrally manage their processes for their civilian medical personnel 
requirements. While local commanders determine these requirements, the 
services may be missing the opportunity to make a strategic 
determination of how many civilian medical professionals are needed to 
carry out their expected workloads. 

What GAO Recommends: 

GAO recommends that OSD and the services emphasize a long-term joint 
approach to medical personnel requirements determination by 
identifying the common medical capabilities shared across the services 
and developing cross-service medical manpower standards, where 
applicable; and that the services take actions to improve their 
respective medical requirements determination processes. In written 
comments to a draft of this report, DOD generally concurred with these 
recommendations. 

View [hyperlink, http://www.gao.gov/products/GAO-10-696] or key 
components. For more information, contact Brenda S. Farrell at (202) 
512-3604 or farrellb@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

DOD's Policy Emphasizes Jointness, although the Services' 
Collaborative Efforts in Determining Medical Personnel Requirements 
Have Been Limited: 

The Services' Respective Processes for Developing Requirements Are Not 
in All Cases, Validated and Verifiable, and Do Not Centrally Account 
for Civilian Personnel Requirements: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Summary of Fiscal Year 2009 Active Duty Medical Personnel 
Levels: 

Appendix III: Comments from the Department of Defense: 

Appendix IV: GAO Contacts and Staff Acknowledgments: 

Table: 

Table 1: Fiscal Year 2009 Requirements, Authorized Positions, and End 
Strengths by Service and Specialty: 

Figures: 

Figure 1: Distribution of Active Duty, Reserve, and Civilian Workforce 
in Total and Specifically for Medical Workforce, by Service: 

Figure 2: Distribution of Active Duty Medical Personnel by Specialty: 

Abbreviations: 

BRAC: Base Realignment and Closure: 

DOD: Department of Defense: 

GAO: Government Accountability Office: 

OSD: Office of the Secretary of Defense: 

PHRAMS: Psychological Health Risk-Adjusted Model for Staffing: 

[End of section] 

United States Government Accountability Office:
Washington, DC 20548: 

July 29, 2010: 

Congressional Committees: 

The physicians, dentists, nurses, and other health care personnel who 
work for the Department of Defense (DOD) are in great demand due to 
projected nationwide medical personnel shortages over the next decade 
and are essential to maintaining DOD's substantial health care 
delivery capability, which provides a full range of medical care to 
active duty military personnel and all other eligible beneficiaries 
sometimes at no cost.[Footnote 1] With more than 9.6 million eligible 
beneficiaries receiving care from DOD's 59 inpatient medical 
facilities, 364 health clinics, and, at times, private-sector 
providers, the cost of DOD's medical system has risen from $17.4 
billion in fiscal year 2000[Footnote 2] to approximately $50 billion 
in fiscal year 2010, and it currently represents more than 9 percent 
of the DOD budget. Moreover, health care costs are expected to 
continue to escalate in the future. Because this amount does not 
include the cost of health care that is needed overseas to support two 
concurrent wars, or the costs to recruit and retain military 
personnel, the total amount DOD is spending on military health care is 
even higher. U.S. forces are expected to continue operations in Iraq 
and Afghanistan and, as a result, add to the workload of military 
treatment facilities for servicemembers who become injured or ill. 
Although tremendous advances in military medicine have led to reduced 
mortality rates among U.S. servicemembers, these patients may require 
lengthy hospital stays and extensive rehabilitation with highly 
trained staff to meet their medical care needs. A higher demand for 
health care personnel is also anticipated due to the increased numbers 
of overall personnel in both the Army and the Marine Corps from an 
effort known as Grow the Force. Key in its efforts to address the 
challenge of managing the medical forces across the services and 
determining the right number and mix of medical personnel to meet the 
various needs of the Military Health System is DOD's plan to promote 
collaboration and integration in human capital management, while 
simultaneously respecting service-specific doctrine. Further, DOD's 
implementation of several strategic initiatives, such as Base 
Realignment and Closure decisions and the development of several joint 
ventures under its evolving framework for a Joint/Unified Medical 
Command, have forced the department to undertake steps designed to re- 
examine, among other things, its medical personnel requirements. 

Our previous work has highlighted a range of long-standing issues 
surrounding DOD's Military Health System. For example, we reported in 
March 1995 that interservice rivalries and conflicting 
responsibilities hindered Military Health System improvement efforts. 
[Footnote 3] We noted in that report that the services have 
historically resisted efforts to change, preferring to maintain their 
own health care systems, primarily on the grounds that each service 
has unique medical activities and requirements. In our February 2005 
report on challenges facing the U.S. government in the 21st century, 
we identified DOD's health care system as an area in which DOD could 
achieve economies of scale and improve delivery by combining, 
realigning, or otherwise changing selected support functions.[Footnote 
4] That report noted that although DOD's civilian and military leaders 
appear committed to reform, DOD must overcome cultural resistance in 
the individual services, as well as the inertia of various 
organizations, policies, and practices (such as "stovepiping" or 
compartmentalizing of information or functions) that became well 
rooted in the Cold War era. In October 2007, we reported that DOD had 
taken incremental steps toward improving efficiencies within its 
Military Health System by establishing a joint medical effort in the 
National Capital Region, as well as the Joint Medical Education and 
Training Center in San Antonio, Texas.[Footnote 5] While we recognized 
that incremental improvements are sometimes appropriate, we 
recommended that DOD take steps to measure whether its efforts were 
meeting the goal of eliminating unnecessary duplication. DOD concurred 
with this recommendation and has identified the steps that the 
department has taken to address it. Further, DOD's April 2006 
Quadrennial Defense Review Roadmap for Medical Transformation 
recognized the department's need to transform its Military Health 
System, and the 2010 Quadrennial Defense Review acknowledged that DOD 
needs to reform the way in which it does business and to eliminate 
challenges that hinder its success. 

The Senate Armed Services Committee, in its report accompanying the 
National Defense Authorization Act for Fiscal Year 2009, directed GAO 
to report to congressional defense committees on medical and dental 
personnel requirements of the Departments of the Army, Navy, and Air 
Force, including their reserve components, in order to, among other 
things, meet their medical missions in support of contingency 
operations and deliver high quality health care to eligible 
beneficiaries.[Footnote 6] In April 2009, we responded to that mandate 
in a published briefing to the defense committees on personnel 
authorizations and end strengths, by medical specialty.[Footnote 7] 
Subsequently, we agreed with congressional defense committees to 
undertake additional related work and initiated two reviews on issues 
related to military medical and dental personnel requirements in 
support of (1) fixed military treatment facilities and (2) contingency 
operations in Iraq and Afghanistan.[Footnote 8] For this report, we 
focused on medical and dental personnel requirements in support of 
DOD's fixed military treatment facilities. We evaluated (1) the extent 
to which the services have incorporated cross-service collaboration in 
their planning efforts for determining their medical personnel 
requirements, and (2) the service-specific processes for determining 
their requirements for military and civilian medical personnel. 

For our first objective, we analyzed DOD and Army, Navy, and Air Force 
policies, directives, and other relevant strategic planning documents. 
We also obtained and analyzed memoranda and other documents related to 
DOD and the services' ongoing collaborative efforts. Further, we 
interviewed various officials from the Office of the Assistant 
Secretary of Defense for Health Affairs and each of the services to 
obtain a more detailed understanding of the history, objectives, 
status, and challenges of their ongoing cross-service medical efforts. 
For our second objective, we analyzed instructions concerning 
personnel management procedures from each of the services. We also 
obtained and examined personnel requirements and authorized positions 
data for selected medical specialties for fiscal year 2009 and 
evaluated the reliability of the data we obtained and analyzed. We 
found it sufficiently reliable for the purposes of this audit. 
Additionally, we obtained and analyzed existing service requirements 
models in use and interviewed officials from each of the services in 
order to understand the processes they implement to determine their 
specific service's medical personnel requirements. For more detailed 
information on our scope and methodology, see appendix I. 

We conducted this performance audit from August 2009 through July 2010 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

DOD's medical mission is twofold in that it maintains a readiness 
mission and a benefits mission. The readiness mission requires DOD to 
maintain the needed availability of its uniformed medical personnel in 
order to support the armed forces during military operations. The 
benefits mission provides servicemembers, retirees, and their 
dependents with access to health care at its military hospitals and 
clinics throughout the United States and overseas. Military medical 
personnel are essential to maintaining DOD's large and complex health 
system and are in great demand because of the need to treat injured or 
ill servicemembers and due to advances in medical technologies that 
require specialized personnel. They simultaneously support contingency 
operations, military operations that are more routine in nature, 
medical research efforts, and the delivery of beneficiary health care 
to patients across the globe. 

The management organization of DOD's Military Health System comprises 
many levels. The Assistant Secretary of Defense for Health Affairs 
[Footnote 9] is the principal advisor for all DOD health policies, 
programs, and force health protection activities, and this official 
reports to the Under Secretary of Defense for Personnel and Readiness, 
who in turn reports to the Secretary of Defense. Health Affairs issues 
policies, procedures, and standards that govern DOD medical programs 
and has the authority to issue DOD instructions, publications, and 
directive-type memoranda that implement policy approved by the 
Secretary of Defense. It integrates the services' submissions and 
prepares, presents, and justifies a unified medical budget that 
provides resources for the Military Health System. Health Affairs is 
also authorized to communicate directly with the heads of DOD 
components regarding these issues.[Footnote 10] Additionally, Health 
Affairs develops policies and standards to ensure effective and 
efficient results through the approved joint process for joint medical 
capabilities integration, clinical standardization, and operational 
validation of all medical material. 

The Secretaries of the Departments of the Army, Navy, and Air Force 
are responsible (subject to the authority, direction, and control of 
the Secretary of Defense) for the operation and efficiency of their 
departments. In addition, the service secretaries issue implementation 
instructions to their departments based on policies that Health 
Affairs develops. By law, the service secretaries are also responsible 
(again, subject to the authority, direction, and control of the 
Secretary of Defense) for promoting cooperation and coordination among 
the military departments and defense agencies to provide effective, 
efficient, and economical administration, and to eliminate 
duplication.[Footnote 11] 

The Army, Navy, and Air Force have their own Surgeons General who have 
overall responsibility for medical operations within their respective 
departments.[Footnote 12] Within the Army, the Army Surgeon General 
simultaneously heads the Army Medical Department and the Army Medical 
Command. In leading the Army Medical Department, the Surgeon General 
serves as the primary advisor to the Secretary of the Army on all 
health and medical issues. In addition, the Army Surgeon General has 
overall responsibility for the Armywide health services system to 
include development, policy direction, organization, and management of 
the system through such activities as recruiting, organizing, 
equipping, supplying, and training, as assigned by the Secretary of 
the Army. As the Commanding General of the Army Medical Command, the 
Surgeon General leads five regional medical commands and their fixed 
military treatment facilities, and other Army Medical Department 
agencies. The Navy Surgeon General serves as the Director of Naval 
Medicine and is the Chief of the Navy Bureau of Medicine and Surgery. 
As the director of Naval Medicine, the Surgeon General is the 
principal advisor to the Chief of Naval Operations on health care 
service programs for the Department of the Navy, and develops and 
issues health care policies and directions. As the chief of the Navy 
Bureau of Medicine and Surgery, the Surgeon General oversees the 
delivery of health care in the Navy and Marine Corps and commands the 
Navy shore medical facilities. The Air Force Surgeon General is that 
service's most senior medical officer and head of the Air Force 
Medical Service. The Air Force Surgeon General is responsible for 
guidance, direction, and oversight for all matters pertaining to the 
formulation, review, and execution of plans, policies, programs, and 
budgets related to carrying out the mission of the Air Force Medical 
System to provide for the health care of Air Force personnel and their 
families. 

The service medical components contribute to the Military Health 
System missions by operating military treatment facilities throughout 
the United States and the world. These facilities consist of 59 
hospitals capable of providing diagnostic, therapeutic, and inpatient 
care, as well as hundreds of clinics that primarily handle health 
screenings and ambulatory care. The Army, Navy, and Air Force staff 
their military treatment facilities with active duty, reserve, and 
civilian personnel. Contractors also play a role in the execution of 
the Military Health System mission by providing medical, clinical, and 
administrative staff and support services within both the military 
treatment facilities and the network of private hospitals and 
providers in the community. Reliance on contractors in the medical 
community varies by location and need. DOD is not required by law to 
include the number of medical contractors it employs in its annual 
Defense Manpower Requirements Report; therefore, the number of medical 
contractors onboard at any point in time is not readily available. 
DOD's medical force is comprised of approximately 228,000 personnel, 
including about 116,000 active duty personnel, 67,000 reserve 
component personnel, and 45,000 civilians. As seen in figure 1, the 
distribution of the medical workforce is fairly proportional to the 
distribution of the total workforce for each of the three services. 

Figure 1: Distribution of Active Duty, Reserve, and Civilian Workforce 
in Total and Specifically for Medical Workforce, by Service: 

[Refer to PDF for image: 2 pie-charts] 

Distribution of total workforce: 
Air Force: 679,100: 24%; 
Navy: 819,900: 29%; 
Army: 1,310,100: 47%. 

Distribution of medical workforce: 
Air Force: 54,098: 24%; 
Navy: 52,576: 23%; 
Army: 121,432: 53%. 

Source: Fiscal Year 2009 Defense Manpower Requirements Report. 

[End of figure] 

Although the personnel distribution varies by service, collectively 
the active duty and reserve workforces make up approximately 80 
percent of the medical force, with the active duty comprising about 51 
percent and the reserves 29 percent. Civilians comprise 20 percent of 
the medical workforce. In providing technical comments to a draft of 
this report, DOD noted that among the military services, the Army has 
the highest percentage of civilians. For example, within the Army 
Medical Command, 58 percent of its fiscal year 2011 medical workforce 
is projected to be comprised of Army civilians. 

According to the 2007 Military Health System Human Capital Strategic 
Plan, the medical workforce is comprised of several specialty medical 
corps, including Medical, Dental, Nurse, Medical Service, Medical 
Specialist, Biomedical Sciences, Veterinary, Warrant Officers, Medical 
Enlisted, and Dental Enlisted. This plan also states that the largest 
corps is the active duty Medical Enlisted Corps, which consists of 
about 75,000 individuals and makes up about 65 percent of DOD's active 
duty medical force. Figure 2 represents the distribution of active 
duty medical personnel by specialty. 

Figure 2: Distribution of Active Duty Medical Personnel by Specialty: 

[Refer to PDF for image: pie-chart] 

Medical enlisted: 75,084: 65%; 
Medical: 11,432: 10%; 
Nurse: 9,332: 8%; 
Medical services: 7,676: 7%; 
Dental enlisted: 5,725: 5%; 
Dental: 2,843: 2%; 
Other: Biomedical sciences: 2,134; Medical specialist: 1,175; 
Veterinary: 430; Warrant officers: 140: 3%. 

Source: Fiscal Year 2009 Defense Manpower Requirements Report. 

[End of figure] 

A more detailed breakout of each of the services' medical specialty 
personnel levels is presented in appendix II. That appendix shows, for 
fiscal year 2009, how each of the services allocated its positions 
within each of its medical specialties based on identified needs, 
financial resources, and personnel availability. 

DOD's Policy Emphasizes Jointness, although the Services' 
Collaborative Efforts in Determining Medical Personnel Requirements 
Have Been Limited: 

While DOD has emphasized jointness and undertaken joint initiatives 
across the department, the extent to which the services have 
incorporated cross-service collaboration in their planning efforts for 
determining their medical personnel requirements has been limited. The 
2007 Military Health System Human Capital Strategic Plan 2008-2013 
emphasizes the importance of planning, coordinating, collaborating, 
and developing human capital solutions across the services to enable 
departmentwide decision making.[Footnote 13] Additionally, a DOD 
directive requires developing plans and procedures and pursuing common 
and cross-cutting modeling tools and data.[Footnote 14] Furthermore, 
DOD is moving toward having joint medical regions in which DOD-
operated medical treatment facilities are staffed using personnel from 
across the service such as the consolidation of the military treatment 
facilities in the Washington, D.C., area. Also, DOD established a 
cross-service, baseline medical manpower standard for mental health 
providers, which was released in January 2010. While these efforts 
represent progress by the services in working collaboratively, the 
services have encountered challenges in their implementation. 

DOD Emphasizes Jointness in Its Strategic Plan and Quadrennial Defense 
Review: 

Issued in November 2007, DOD's medical personnel strategic plan--the 
Military Health System Human Capital Strategic Plan 2008-2013-- 
emphasizes coordination and collaboration across the services. This 
plan sets forth a vision, guiding principles, goals, and objectives 
for the management of the Military Health System's medical personnel. 
The strategic plan articulates a vision of an interoperable and agile 
total medical force that meets the missions defined by National 
Security Strategy requirements. Emphasized throughout this strategic 
plan is the premise that the mission of the Military Health System can 
be better met by increasing emphasis on planning, coordinating, 
collaborating, and developing human capital solutions across the 
services. More specifically, this strategic plan states that the 
Military Health System cannot continue to recruit, develop, train, 
reward, and retain its workforce solely through each service 
independently, as mission requirements demand that they work together 
to achieve interoperability and agility. 

The 2007 Military Health System Human Capital Strategic Plan also 
aligns with critical areas on medical transformation initially 
presented in the April 2006 Quadrennial Defense Review Roadmap for 
Medical Transformation, which encouraged the Military Health System to 
create standardized processes, tools, and resources to improve 
efficiency and eliminate redundancies across the services. This goal 
is reiterated by a specific DOD directive requiring the services to 
maximize commonality, reuse, interoperability, efficiencies, and 
effectiveness of component-specific modeling data and tools. The 
Military Health System Strategic Plan is also cited in the 2010 
Quadrennial Defense Review, which generally observes that DOD needs to 
reform the way in which it does business to address challenges--such 
as parochial interests and sometimes adversarial relationships within 
the Pentagon and with other parts of government--that are hindering 
its success. 

Joint Medical Effort in the Washington, D.C., Area Represents Cross- 
Service Collaboration but Has Encountered Challenges in Developing Its 
Military Medical Personnel Requirements: 

To eliminate redundancies in medical operations, integrate services, 
and achieve better economies of scale, DOD is implementing a joint 
medical effort in the National Capital Region of Washington, D.C., 
known as Joint Task Force National Capital Region Medical. This effort 
stems from a 2005 Base Realignment and Closure (BRAC) Commission 
recommendation to relocate patient care activities from the Walter 
Reed Army Medical Center Washington, D.C., to the National Naval 
Medical Center, Bethesda, Maryland, and to a new community hospital at 
Fort Belvoir, Virginia. The BRAC Commission presented its list of 
final recommendations to the President of the United States, which 
included a cost/savings estimate for this joint medical effort. The 
President approved the recommendations in their entirety and 
subsequently forwarded them to Congress, and they became effective in 
November 2005. Our analysis of DOD fiscal year 2010 BRAC budget showed 
that the cost to implement this realignment is estimated to be $2.4 
billion, consisting primarily of $1.7 billion in construction costs. 
That analysis also showed that DOD projects its net annual recurring 
savings of this effort to be $172 million.[Footnote 15] 

In September 2007, the Deputy Secretary of Defense issued a memorandum 
that formally established Joint Task Force National Capital Region 
Medical. One of its two facilities, the new Walter Reed National 
Military Medical Center, will be located on the Bethesda campus, and 
according to the Deputy Secretary of Defense, is expected to deliver 
effective and efficient, world-class military health care, as well as 
consolidate and realign military health care in the region. Its 
medical services will include primary care, secondary care (that is, 
care provided by a consulting physician at the request of a primary 
physician), and tertiary care (that is, very specialized care 
performed by physicians with facilities and skills for special 
investigation and medical treatment). DOD plans to close the current 
Walter Reed Army Medical Center facility by September 2011. The second 
facility at Fort Belvoir, Virginia, is being expanded to provide 
comprehensive primary and secondary patient care services. Joint Task 
Force National Capital Region Medical's vision, mission, and 
principles include as a key priority the establishment of common 
standards and processes, and calls for interoperability. According to 
a statement in the 2010 Comprehensive Master Plan for the Nation 
Capital Region Medical, this medical realignment represents a merger 
of nearly 10,000 healthcare and support staff. The document also 
states that the department has currently determined an active duty 
personnel distribution between the new Walter Reed National Military 
Medical Center in Bethesda and the Fort Belvoir Community Hospital, 
and that the services have identified the resources to meet the 
manning requirements. Joint Task Force National Capital Region 
Medical, which reached fully operational capability status on 
September 30, 2008, represents an important initiative within the 
Military Health System because, if successful, Joint Task Force 
officials believe it will be a model for the future of military 
medicine. Officials also noted to us that this joint medical effort in 
Washington, D.C., is a new process and, Joint Task Force officials are 
working with the services to work through details to achieve joint 
medical commands in the National Capital Region. 

Officials, however, have faced challenges in consolidating and 
realigning the medical manpower portion of this newly formed joint 
medical effort within the National Capital Region. Additionally, 
according to officials we spoke with, several assumptions used 
throughout the development of the joint manning document--that (1) the 
population served would remain static from 2004, (2) the clinical 
workload to be met would be based on that of 2004, and (3) the 2004 
medical missions would remain constant--have become outdated. 
According to officials, the military treatment facilities in the 
National Capital Region have seen a significant increase in their 
clinical workload over 2004 levels as a result of injuries sustained 
by servicemembers following the acceleration in overseas operations in 
Iraq that was announced in 2007. Further, they said these injuries 
entail additional medical missions that the Joint Task Force officials 
have not been able to fully incorporate into the clinical workload or 
the personnel requirements determination. Such additional missions 
include an increased need for advanced limb and wound care, and 
traumatic brain injury care. Also, in order to develop the joint 
manning document for the newly formed and jointly staffed facilities, 
officials had to fuse the results of the services' dissimilar medical 
personnel requirements determination processes. In doing so, they 
found that the services' official manning documents contained 
inaccuracies. Several civilian and military Joint Task Force 
officials, who analyzed manpower documents to determine the levels of 
medical personnel currently on board for each service, told us that 
the services had employed civilian and contract personnel at their 
facilities but not recorded them on the manpower documents upon which 
these officials based the development of the joint manning document. 
For these various reasons, the joint task force officials have 
encountered significant challenges in developing an accurate, 
complete, and realistic joint manning document that lays out the 
medical requirements by specialty for the newly formed joint 
facilities. 

DOD officials attribute the problems to formative, early stage 
development issues, and acknowledged that, if service manpower 
determination processes had used similar language, nomenclatures, and 
approaches, the creation of the joint manning document would have been 
a more straightforward process. Officials also told us, however, that 
while the collaboration encountered to date has been challenging, it 
has been beneficial in building the relationship among the medical 
components and operational components of the services. These officials 
stated that with continued collaboration among the services and future 
operational experience, the Joint Task Force's leadership intends to 
identify data-driven refinements to projected manpower requirements 
that would better capture efficiencies, enhance service quality, and 
build on selected strategic interests. 

DOD and the Services Collaborated to Develop a Recently Released Cross-
Service Medical Manpower Standard for Mental Health Providers: 

A second joint medical personnel effort, quite different from that of 
the realignment previously described, is DOD and the services' ongoing 
development and implementation of a cross-service medical manpower 
standard known as the Psychological Health Risk-Adjusted Model for 
Staffing (PHRAMS). PHRAMS represents the culmination of a 
collaborative manpower requirements effort to develop a standardized, 
more consistent approach across the services for determining mental 
health personnel requirements. Health Affairs sponsored the 
development of the cross-service PHRAMS manpower standard to address 
the growth in demand for mental health services, as well as to give 
the services a standard by which to develop mental health requirements 
needed to meet the common, day-to-day psychological health needs of 
eligible beneficiaries across the services. The model projects mental 
health medical requirements over a 5-year planning horizon and 
provides a gap analysis for the first year, in order to assist the 
services in addressing near-term personnel shortages. It also provides 
a consistent staffing standard containing several fixed parameters, 
such as the size of the beneficiary population and utilization rates, 
which Health Affairs will re-evaluate annually when the model is 
updated. Finally, the model contains variables that can change at the 
services' discretion, such as the number of patients seen annually by 
a provider and an adjustment rate to reflect increased deployments for 
servicemembers in the hospital's area of responsibility. Health 
Affairs released the final model to the services in January 2010. 
Currently, the Army, Navy, and Air Force are using PHRAMS to generate 
mental health staffing requirements at their military treatment 
facilities that are to be incorporated into the fiscal year 2012 
budget submission later this year and because the model was only 
recently released to the services, the effect of its implementation on 
cost savings or requirement numbers is still unknown. Additionally, 
Health Affairs officials said that the services will continue to 
assess potential applications of PHRAMS. While the services are not 
specifically required to use PHRAMS or to develop more models, Health 
Affairs officials told us that the publishing of the Military Health 
System Human Capital Strategic Plan has encouraged dialogue among the 
services on collaboration, and such dialogue may facilitate the 
identification of further opportunities for development of manpower 
requirements models. 

Service-Specific Medical Requirements Determination Processes Are Not 
Consistent with Collaborative Planning: 

To the extent that PHRAMS represents a positive collaborative 
initiative, to date it is the only model of its kind. The services are 
responsible for organizing, equipping, and training their respective 
forces, and service officials assert that their respective needs are 
sufficiently different to warrant maintaining service-unique processes 
for requirement determination. While each of the services has unique 
operational medical capabilities, such as Army veterinary medicine, 
Navy undersea medicine, and Air Force aerospace medicine, the day-to- 
day operations at military medical treatment facilities are very 
similar across the services, and they could advantageously be more 
collaboratively managed. A DOD directive requires the respective heads 
of the services to maximize the commonality, reuse, interoperability, 
efficiencies, and effectiveness of component-specific modeling data 
and tools,[Footnote 16] but Health Affairs officials said that no 
other current collaboration efforts for determining medical personnel 
requirements or developing medical manpower standards, other than 
PHRAMS, are currently under way. Committed and effective leadership is 
a critical aspect of enhancing collaboration. Committed leadership by 
those involved in collaborative efforts from all levels of the 
organization is needed to overcome the many barriers to working across 
boundaries. Key organizational issues, like strategic workforce 
planning, are most likely to succeed if, at their outset, top program 
and human capital leaders set the direction, pace, and tone and 
provide a clear, consistent rationale for the transformation. With 
leadership emphasis and expectations that the services will continue 
to explore opportunities to develop cross-service medical manpower 
standards, such as PHRAMS, and consistent management focus on 
collaboration within DOD's Military Health System, the services will 
have more opportunities to develop collaborative work force planning 
efforts for common medical capabilities that they share throughout 
their military treatment facilities--an approach that is consistent 
with the Military Health System Human Capital Strategic Plan's vision 
of a more integrated approach across service lines.[Footnote 17] 

The Services' Respective Processes for Developing Requirements Are Not 
Validated and Verifiable in All Cases and Do Not Centrally Account for 
Civilian Personnel Requirements: 

While a need exists for the services to work more collaboratively to 
determine their medical personnel requirements, the services' also 
maintain processes to address service-specific needs. In accordance 
with a DOD directive,[Footnote 18] personnel requirements are to be 
established according to workload at the minimum levels necessary to 
accomplish mission and performance objectives. Additionally, a DOD 
instruction[Footnote 19] calls for the models and associated data used 
to support DOD processes and decisions to be validated and verified 
throughout their life cycles, and accredited for the model's intended 
purpose. While all of the services currently are taking steps to 
update and refine their medical personnel requirement processes, these 
processes, however, are not yet fully validated or verifiable. 
Further, the services do not centrally manage their civilian medical 
personnel requirements. 

Army's Model Contains Some Outdated Information and Is in the Process 
of Being Updated and Validated: 

The Army uses its Automated Staffing Assessment Model to determine 
manpower requirements for Army fixed military treatment facility and 
other Army Medical Command organizations. This model is based 
primarily on approved population and workload data, but it also 
incorporates industry performance data to determine manpower 
requirements for the various medical specialties. The Automated 
Staffing Assessment Model consists of over 240 modules for determining 
essential medical requirements for many medical specialties such as 
physicians, nurses, dentists, medical service corps, and 
veterinarians, to name a few, at the work center level across Army 
fixed military treatment facilities. The model uses the current 
population of the various military treatment facilities as the major 
determinant of the number of medical personnel needed at each 
facility. In addition, a number of key, workload-based assumptions 
inform the model, including patient care hours, population 
projections, provider-to-patient ratio, and provider-to-support 
technician ratio. However, in certain cases, our analyses of selected 
modules revealed areas that need improvement. For example, our 
analyses of the inpatient nursing and dental modules revealed the use 
of some obsolete assumptions. Specifically, we found that the Army's 
nursing requirements module had not been updated or used since 2005 to 
determine nursing requirements. Further, according to dental command 
officials, the dental module in use is an Army legacy model that is 
over 40 years old and does not reflect the more advanced level of 
dental care currently being provided, such as the increased need for 
complex dental repair work rather than simple extractions. DOD noted 
in technical comments on a draft of this report that the nursing and 
dental modules were recently updated and submitted for validation. 

According to Army officials, updates to Army medical manpower models 
are subject to a review process by the U.S. Army Manpower Analysis 
Agency, and to final approval by the Office of the Assistant Secretary 
of the Army for Manpower and Reserve Affairs. A module can be approved 
for 3 years if it is determined to be logical, analytical, verifiable, 
and based on accurate data sources. However, if a module is based 
solely on data provided by subject matter experts and functional 
estimates of the primary tasks associated with the specialty, the 
model will be approved for 1 year--as is the case for the recently 
validated veterinary specialty module. According to Army officials, 
prior to 2008, the Army required a random sample of 2 percent of the 
requirements models to be validated for reasonableness; however, 
currently, it uses a more stringent approach that requires all models 
to be validated. Army documents show that the Army's manpower analysis 
agency completed validation of 4 of the 240 modules in 2009 and 2 more 
so far in 2010. In addition, 12 more modules have either been 
submitted for review and approval or are nearing submission. In 
technical comments to a draft of this report, DOD noted that the Army 
believes the number of requirements covered by its staffing assessment 
model is more important than the number of modules as we have 
discussed. As such, the Army noted that nearly 20 percent of its 
medical personnel requirements have been updated and about another 20 
percent of its requirements have been submitted for validation however 
are pending approvals. Moreover, Army Medical Command officials have 
been working with representatives from the Army Manpower Analysis 
Agency to develop a specific time line and priorities for validation 
of the remaining modules, but currently no definitive schedule has 
been set yet for completing the validation. 

Army officials recognized that the approach to model validation that 
they had been using, including its previous reliance on sampling 
methods, was not providing the Army with complete and sufficient 
information. With committed and sustained leadership emphasis to 
complete and maintain the validation of all the modules, the Army will 
be in a better position to be certain it is determining its medical 
personnel requirements in an effective and efficient manner. 

Navy Does Not Have a Validated and Verifiable Process but Is Moving 
toward a Validated Model: 

The Navy has not used a model to determine the medical personnel 
requirements for its fixed military treatment facilities. Instead, 
Navy officials explained that, the Navy's process is to use current 
manning as a baseline and adjust the figure based on emerging needs or 
major changes in its medical mission. Additionally, Navy officials 
explained that local military treatment facility commanders prepare 
annual business plans for their medical facilities and include 
proposed changes to the facilities' personnel requirements based on 
such information as enrolled population, utilization rates, and on 
expert functional knowledge at the military treatment facility. These 
business case analyses are then submitted and reviewed through the 
chain of command and approved by the Navy Surgeon General as medical 
resources allow. While the Navy routinely employs this approach to 
determine its medical personnel requirements, it is not a validated or 
verified methodology as required by DOD guidance. 

To better assess its medical personnel requirement needs at the 
medical specialty level, the Navy is beginning to develop medical 
manpower standards which officials indicate will be used as the basis 
for future requirements determination. According to Navy officials, 
they plan to use the Navy Medicine Benchmark Model for its 93 medical 
functional areas. As this model will determine the benchmark for the 
number of personnel needed in a medical specialty at a military 
treatment facility, the model will be used to identify surpluses or 
shortages in personnel at each facility and identifying the optimal 
military, civilian, and contractor mix. DOD noted in technical 
comments responding to a draft of this report that the Navy Bureau of 
Medicine and Surgery Headquarters is the approval authority for 
determining whether a medical personnel requirements model or process 
is valid and verifiable. Navy medical officials explained that they 
are still in the process of determining the model's validity for each 
of its medical specialty areas, and they did not provide a time 
schedule as to when this would be completed. Although the Navy is 
implementing this model to help determine its medical personnel 
requirements, Navy officials asserted to us that the Navy does not 
have any unmet requirements, as it uses private-sector medical care 
when military treatment facilities are unable to provide the care. 

Navy officials recognized the business case analysis process did not 
provide the validated and verifiable approach needed to determine 
their medical manpower requirements. With committed and sustained 
leadership emphasis to implement and maintain a fully validated 
benchmark model, the Navy similarly will be in a better position to be 
certain it is determining its medical personnel requirements in an 
effective and efficient manner. 

Air Force Currently Uses a Nonvalidated, Nonverifiable Model and Other 
Information to Determine Its Medical Requirements but Has Begun 
Developing a Newer Model: 

In 2002, the Air Force Surgeon General collaborated with the private 
sector to design the Product Line Analysis and Transformation Tool 
that produced medical manpower staffing models utilizing industry 
standards and research and the experiences of Air Force medical 
personnel. While the models were presented in 2003 for validation and 
approval, the Air Force leadership did not approve this model for 
determining manpower standards for its medical specialties because the 
models were not based on objectively quantifiable data sources. 
Although the Air Force considered any medical requirements developed 
using the model as unverifiable, it allowed Air Force medical 
officials to continue to use the models as a part of its requirements 
determination process. Currently, Air Force medical officials use, in 
addition to the model, historical workload, historical and like-size 
facility manning, industry models, functional models, and statistical 
analysis of variance by facility to generate their medical personnel 
requirements. The current requirements development process can be 
performed using either a top-down or a bottom-up approach. The top-
down approach begins with Air Force leadership, usually at the rank of 
general, determining that a military treatment facility has a need for 
new requirements. The bottom-up approach occurs when officials at a 
military treatment facility identify a need for a new requirement and 
then work through the major commands to change or alter its current 
requirements. The major commands then work with the Air Force Medical 
Operations Agency to bring a request for new or changed requirements 
to the Air Force Surgeon General. The new or changed requirements 
undergo a vetting process that ranges from the military treatment 
facility to the Chief of Staff before they are approved. Any changes 
to requirements are based on identified need as experts in functional 
areas obtain new data or refined standards. 

To establish the feasibility of providing a verifiable means of 
medical manpower standards development support to the Air Force 
medical community, the Air Force Medical Service and the Air Force 
Manpower Agency signed a Memorandum of Agreement whereby the Air Force 
Manpower Agency will develop new manpower standards for all Air Force 
medical specialties, based on data that have been collected for each. 
According to officials, this effort began in January 2010, and they 
hope to have completed developing all of the manpower standards by 
2015. In order to do so, the Air Force Manpower Agency is planning to 
hire 15 officials--10 civilians and 5 military--to research, develop, 
and validate the new manpower standards. This effort will include such 
tasks as developing the data collection approach, performing the 
analysis on all of the data, developing the manpower models, and 
identifying process improvement opportunities. 

Air Force officials recognized that their recent efforts to develop 
medical manpower standards stem from the Air Force's need for a 
validated and verifiable manpower requirements determination process. 
With committed and sustained leadership emphasis on maintaining 
validated medical manpower models, the Air Force is in a similar 
position as the other services in that it would be in a better 
position to know its true medical needs by medical specialty and to be 
certain it is determining its medical personnel requirements in a more 
effective and efficient manner. 

The Services Do Not Centrally Account for Civilian Personnel 
Requirements: 

DOD's efforts to determine its medical personnel requirements at 
military treatment facilities are further limited by the fact that the 
services have not fully incorporated into their requirements processes 
the use of civilians who deliver health care at the same stage in the 
process where they determine their military medical personnel 
requirements. A DOD directive requires that, for areas employing both 
military and civilian personnel, manpower requirements shall be 
determined in total and designated as either military or civilian, but 
not both, as an active, reserve, or civilian determination must be 
made for each requirement.[Footnote 20] The Military Health System 
Human Capital Strategic Plan also asserts that more efforts should be 
made to have the optimal mix of medical personnel. However, while 
civilian personnel constitute about 20 percent of the services' 
medical workforce, the services' current requirements processes are 
generic in nature and do not differentiate positions as military or 
civilian.[Footnote 21] We found that all three services first 
determine their collective requirements. Then, at the local level, 
after all of the positions at a military treatment facility are 
staffed with the available military personnel, the commander of the 
local military treatment facility determines whether a position will 
be designated as civilian or contractor. In making determinations to 
use civilian personnel, local commanders use several factors, such as 
whether the position is military essential--to support readiness or 
operational missions--or inherently governmental--which would require 
the position be filled with a government employee. Additionally, 
commanders consider financial resources and the availability of 
civilian or contractor personnel in the local area. In technical 
comments provided in response to a draft of this report, DOD officials 
disagreed with our statement that the services do not centrally 
account for civilian personnel requirements. DOD noted that workload 
generated by civilians is captured and depicted in a centralized 
information management system. However, based on the explanation of 
this system given by DOD, we note that this system captures the number 
of civilian personnel already on board and the areas in which they are 
employed. It does not identify the number of civilian personnel needed 
and required by each service to meet the missions of fixed military 
treatment facilities, nor does it centrally account for civilian 
personnel requirements. In addition, several military treatment 
facility personnel told us that more direction or centralized guidance 
would aid them, in many cases, in their management of their civilian 
personnel. DOD's 2009 update to its Civilian Human Capital Strategic 
Plan[Footnote 22] lists global civilian end strength numbers for five 
mission critical medical occupational series--medical officers, 
nurses, pharmacists, clinical psychologists, and licensed clinical 
social workers. This update also gives projected accession and 
recruiting goals needed to reach those global end strength numbers. 
However, the update does not project any civilian end strength numbers 
at the medical specialty levels within these occupational series nor 
does it indicate the military treatment facilities at which these 
civilians are needed. If the services do not identify civilian 
personnel requirements for military treatment facilities in the 
overall requirements planning process, the services may be missing the 
opportunity to make a strategic determination of how many medical 
professionals--military or civilian--are needed in total to carry out 
their expected missions and workloads. The services assume added risk 
if their medical requirements are not completely met, and if the 
requirements are unknown, the extent of that risk cannot be estimated. 
If risk is unknown, the services cannot develop appropriate risk-
mitigation strategies for their unmet medical personnel requirements. 

Conclusions: 

To achieve a military health system that can respond to our country's 
changing national security needs by using both the right numbers and 
the right mix of forces, DOD has emphasized the need for collaboration 
of efforts in the medical arena, and committed and sustained 
leadership emphasis is key to successful collaboration. The efforts 
taken to date by OSD and the services to develop and implement 
specific cross-service manpower related programs have been a step in 
the right direction for building a collaborative approach to 
determining military medical personnel requirements. As such, it is 
important that the services continue to focus on developing programs, 
solutions, and measures for managing medical personnel requirements 
across the services and focus on the long-term, broader picture. By 
doing so, OSD and the services will have more opportunities to create 
departmentwide benefits and would more fully support the Military 
Health System's strategic planning goal of collaboration. Also, as the 
services work toward a joint approach, it is important for them to 
have sound medical personnel requirement determination processes in 
place, to enable them to identify the personnel numbers and mix they 
need to fully perform their medical missions. If the services are to 
effectively and efficiently provide daily care to active duty and 
retired servicemembers and their dependents in their fixed medical 
facilities, it is important that each of their medical personnel 
requirement processes reflects currency, validation, and verification. 
Areas of improvement exist within the services' medical requirements 
processes, and until these processes are up-to-date, fully validated, 
and verifiable, it is not clear whether the services can be certain 
they are determining their medical personnel requirements in an 
effective and efficient manner. 

Recommendations for Executive Action: 

Consistent with DOD emphasis on developing human capital solutions 
across the services to enable departmentwide decision making and 
analyses within its Military Health System, we recommend that the 
Secretary of Defense direct the Assistant Secretary of Defense for 
Health Affairs and the Service Secretaries to take the following two 
actions. 

* Identify the common medical capabilities that are shared across the 
services in their military treatment facilities that would benefit 
from the development of cross-service medical manpower standards; and: 

* Where applicable, develop and implement cross-service medical 
manpower standards for those common medical capabilities. 

To improve the Army's current medical personnel requirements 
determination process, we recommend that the Secretary of the Army 
direct the Army Surgeon General to take the following three actions. 

* Update assumptions and other key data elements contained within 
specialty modules of the Automated Staffing Assessment Model; 

* Develop and implement a definitive revalidation schedule for the 
specialty modules of the Automated Staffing Assessment Model; and: 

* Include its reliance on civilian medical personnel in its 
assumptions as it updates and validates their medical personnel 
requirements determination modules. 

To improve the Navy's current medical personnel requirements 
determination process, we recommend that the Secretary of the Navy 
direct the Navy Surgeon General to take the following two actions. 

* Develop a validated and verifiable process to determine its medical 
manpower requirements; and: 

* Include its reliance on civilian medical personnel in its 
assumptions as it develops, and then validates, its medical personnel 
requirements determination model. 

To improve the Air Force's current medical personnel requirements 
determination process, we recommend that the Secretary of the Air 
Force direct the Air Force Surgeon General to take the following two 
actions. 

* Develop a validated and verifiable process to determine its medical 
manpower requirements; and: 

* Include its reliance on civilian medical personnel in its 
assumptions as it develops, and then validates, its medical personnel 
requirements determination model. 

Agency Comments and our Evaluation: 

In written comments provided in response to a draft of this report, 
DOD concurred or partially concurred with all of our recommendations. 
DOD's written comments are reprinted in appendix III of this report. 
Additionally, DOD provided technical comments that we have 
incorporated where appropriate. 

In concurring with our recommendations regarding identifying, 
developing, and implementing cross-service medical manpower standards 
for medical capabilities that are shared across the services, DOD 
noted that a cost-benefit analysis must precede a review of shared 
capabilities to ensure that there is a significant, measurable benefit 
in cost, quality, or access to medical care before department medical 
funds are expended. We agree that this course of action would 
constitute a reasonable part of a process to identify which 
specialties would benefit from such efforts. 

In concurring with our recommendations to improve the Army's current 
medical personnel requirements determination process by updating 
assumptions, developing and implementing a revalidation schedule, and 
including its reliance on civilian medical personnel in its 
assumptions, DOD stated that the Army will continue to update 
assumptions and other key data elements within the Army Automated 
Staffing Assessment Model as our recommendation suggested and will 
closely coordinate efforts between Army Medical Command and the U.S. 
Army Manpower Analysis Agency to implement a revalidation schedule for 
the medical personnel requirements determination models. DOD further 
noted in its response to a draft of this report that the Army will 
continue to capture civilian contribution to the generation of medical 
workload in its Automated Staffing Assessment Model, and that 58 
percent of Army Medical Command's workforce is civilian. Although we 
believe Army's efforts to capture civilian contribution is important 
to understanding its workforce, the intent of our recommendation is 
for the Army to better delineate military versus civilian personnel 
requirements during the requirements determination process as called 
for in DOD Directive 1100.4. 

In its partial concurrence with our recommendations for the Navy to 
develop a validated and verifiable process to determine its medical 
manpower requirements and to include its reliance upon civilian 
medical personnel in its assumptions, DOD noted that the Navy 
initiated a comprehensive effort to redefine how medical manpower 
requirements are determined, the results of which are expected by fall 
2010. We note this effort in our report, and it is in line with the 
intent of our recommendation, but we continue to assert the need for 
this effort to be completed. Further, DOD noted that the Navy Surgeon 
General has always taken and will continue to emphasize a total force 
approach in future planning and programming for medical personnel. We 
note, however, that while we recognize the value of such an approach, 
our recommendation concerns, as with the Army, the need for the Navy 
to delineate military versus civilian personnel requirements during 
the requirements determination process as called for in DOD Directive 
1100.4. 

In concurring with our recommendations that the Air Force Surgeon 
General develop a validated and verifiable process to determine 
medical manpower requirements and include its reliance on civilian 
medical personnel in its assumptions, DOD noted that the Air Force is 
in the process of developing new manpower standards for its medical 
specialties, having finalized a Memorandum of Agreement between the 
Air Force Medical Service and Air Force Manpower Agency in May 2010. 
We note the potential of this effort as a strong step toward 
fulfilling this recommendation. Further, DOD noted that the new Air 
Force manpower standards will include the identification of civilian 
equivalents for those positions not deemed military essential, and 
that civilian requirements are also reviewed and determined through 
the Inherently Governmental/Commercial Activity process. We agree that 
Air Force's new medical requirements determination standards, to 
include civilians, will have the potential to address the intent of 
our recommendation. The Inherently Governmental/Commercial Activity 
process, however, does not completely address the need to delineate 
military versus civilian personnel requirements during the 
requirements determination process as our recommendation suggests and 
as called for in DOD Directive 1100.4. 

Additionally, one of DOD's technical comments concerns our 
recommendations regarding the services' need to include their reliance 
on civilian medical personnel in their assumptions when developing and 
validating their medical personnel requirements determination models. 
In this technical comment, DOD suggested that we delete the section of 
our report headed by the statement "The Services Do Not Centrally 
Account for Civilian Personnel Requirements." DOD noted that all three 
services use a reporting system that captures and depicts workload 
generated by civilians in a centralized information management system. 
However, we note that the workload generated by civilians constitutes 
an after-the-fact status of assignments rather than a consideration in 
generating the requirements before these civilians are assigned to 
fill a requirement. Thus, we continue to believe the validity of our 
aforementioned heading reflecting our findings in this area has merit. 

Finally, DOD provided in its technical comments to a draft of this 
report a table that they believe illustrates recent collaborative 
efforts. Two of the six examples--Psychological Health Risk-Adjusted 
Model for Staffing and Joint Task Force National Capital Region 
Medical--are discussed extensively in this report. DOD noted four more 
examples to illustrate recent collaborative efforts, such as proposed 
legislation for financial assistance to provide scholarships to 
civilian medical providers, that we did not include in our report 
because we believe that these examples are not directly related to the 
development of cross-service manpower standards or medical personnel 
requirements, which is the focus of this report. We have, however, 
reprinted DOD's table in appendix III. 

We are sending copies of this report to the Secretary of Defense and 
the Secretaries of the Army, Navy, and Air Force. In addition, the 
report will be available at no charge on the GAO Web site at 
[hyperlink, http://www.gao.gov]. If you or your staff have any 
questions on the information discussed in this report, please contact 
me at (202) 512-3604 or farrellb@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. GAO staff who made key contributions to 
this report are listed in appendix VI. 

Signed by: 

Brenda S. Farrell: 
Director: 
Defense Capabilities and Management: 

List of Committees: 

The Honorable Carl Levin: 
Chairman: 
The Honorable John McCain: 
Ranking Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Daniel K. Inouye: 
Chairman: 
The Honorable Thad Cochran: 
Ranking Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
United States Senate: 

The Honorable Ike Skelton: 
Chairman: 
The Honorable Howard P. McKeon: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

The Honorable Norman D. Dicks: 
Chairman: 
The Honorable C.W. Bill Young: 
Ranking Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
House of Representatives: 

[End of section] 

Appendix I: Scope and Methodology: 

This engagement examines the processes used by the military services 
to determine their medical personnel requirements for staffing, to 
include the number and specialty mix of military and civilian 
employees, at fixed medical treatment facilities. We interviewed 
officials and, where appropriate, obtained documentation at the 
following locations: 

* Office of the Assistant Secretary of Defense for Health Affairs, 
Washington, D.C.; 

* Army Medical Command, San Antonio, Texas; 

* United States Army Manpower Analysis Agency, Fort Belvoir, Virginia; 

* Brooke Army Medical Center, San Antonio, Texas; 

* Navy Bureau of Medicine and Surgery, Washington, D.C.; 

* Navy Medical Support Group, Jacksonville, Florida; 

* Naval Medical Center Portsmouth, Portsmouth, Virginia; 

* Air Force Medical Service, Washington, D.C.; 

* Air Force Manpower Agency, San Antonio, Texas; and, 

* 12th Medical Group--Randolph Air Force Base Clinic, San Antonio, 
Texas. 

To evaluate the extent to which the services have collaborated in 
their strategic planning efforts for the determination of their 
medical personnel requirements, we reviewed manpower, personnel, and 
Military Health System policies and plans for the Department of 
Defense and the services. Especially pertinent were Department of 
Defense Directive 5000.59, on Modeling and Simulation management, and 
the Military Health System Human Capital Strategic Plan for Fiscal 
Years 2008-2013. We compared the guidance, goals, and strategies in 
those documents with the ongoing medical personnel requirements 
determination processes used by the services, which we determined by 
analyzing documentation and interviewing officials from each of the 
locations listed. We also analyzed documentation and interviewed 
officials from Joint Task Force National Capital Region Medical and 
the San Antonio Military Medical Center to learn about joint medical 
operations that are being developed and implemented. Further, we met 
with officials from the Center for Naval Analyses who are currently 
working under a contract with the Office of the Assistant Secretary of 
Defense for Health Affairs to develop a cross-service medical manpower 
standard for behavioral health specialties known as the Psychological 
Health Risk-Adjusted Model for Staffing. 

To evaluate the service-specific processes for determining their 
requirements for military and civilian medical personnel, we reviewed 
documentation provided to us by officials, whom we then interviewed, 
from each of the offices previously cited. We obtained and reviewed 
the Army's Automated Staffing Assessment Model for four medical 
specialties: physicians, dentists, nurses, and mental health care. We 
interviewed agency officials who operate the models for each of these 
specialties to understand how these models are used, how accurate the 
data are, and whether the models had been validated by the Army's 
Manpower Analysis Agency. We additionally interviewed officials from 
the Navy Bureau of Medicine and Surgery and the Air Force Medical 
Service regarding the processes they use to determine their medical 
manpower requirements. We also collected data on medical personnel 
requirements, authorized positions, and end strengths for fiscal year 
2009 from each of the services' medical departments and from the 
Defense Manpower Data Center's Health Manpower Statistics Report. The 
Army is the only service that provided service-specific data, while 
the Air Force and Navy deferred to the Defense Manpower Data Center's 
Health Manpower Statistics Report. We coordinated our analysis and our 
results with a methodologist from GAO's Applied Research and Methods 
team. Additionally, with guidance from the methodologist, we also 
evaluated the reliability of the data we obtained and found it 
sufficiently reliable for the purposes of this audit. 

We conducted this performance audit from August 2009 through July 2010 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: Summary of Fiscal Year 2009 Active Duty Medical Personnel 
Levels: 

The following data show the results of service-specific medical 
personnel requirement processes (where available) in comparison with 
funded and filled positions. 

Table 1: Fiscal Year 2009 Requirements, Authorized Positions, and End 
Strengths by Service and Specialty: 

Specialty: Allergy/Immunology;
Army: Requirement: 32;
Army: Authorized: 29;
Army: Strength: 39;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 5;
Navy: Strength: 3;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 13;
Air Force: Strength: 20. 

Specialty: Anesthesiology;
Army: Requirement: 158;
Army: Authorized: 137;
Army: Strength: 162;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 123;
Navy: Strength: 142;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 80;
Air Force: Strength: 91. 

Specialty: Aviation/Aerospace Medicine;
Army: Requirement: 76;
Army: Authorized: 56;
Army: Strength: 29;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 0;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 213;
Air Force: Strength: 182. 

Specialty: Aviation/Aerospace Medicine Non-Residency Trained;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 215;
Navy: Strength: 219;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 151;
Air Force: Strength: 189. 

Specialty: Aviation/Aerospace Medicine Residency Trained;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 64;
Navy: Strength: 47;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 264;
Air Force: Strength: 47. 

Specialty: Cardiac/Thoracic Surgery;
Army: Requirement: 20;
Army: Authorized: 19;
Army: Strength: 19;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 15;
Navy: Strength: 8;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 7;
Air Force: Strength: 8. 

Specialty: Cardiology;
Army: Requirement: 69;
Army: Authorized: 65;
Army: Strength: 80;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 30;
Navy: Strength: 34;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 26;
Air Force: Strength: 30. 

Specialty: Colon/Rectal Surgery;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 9;
Navy: Strength: 13;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 7;
Air Force: Strength: 7. 

Specialty: Critical Care/Trauma Medicine;
Army: Requirement: 12;
Army: Authorized: 12;
Army: Strength: 9;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 28;
Navy: Strength: 1;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 0;
Air Force: Strength: 1. 

Specialty: Critical Care/Trauma Surgery;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 19;
Navy: Strength: 17;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 17;
Air Force: Strength: 17. 

Specialty: Dermatology;
Army: Requirement: 71;
Army: Authorized: 67;
Army: Strength: 91;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 31;
Navy: Strength: 33;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 25;
Air Force: Strength: 25. 

Specialty: Emergency Medicine;
Army: Requirement: 189;
Army: Authorized: 162;
Army: Strength: 218;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 117;
Navy: Strength: 140;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 94;
Air Force: Strength: 139. 

Specialty: Endocrinology;
Army: Requirement: 17;
Army: Authorized: 16;
Army: Strength: 20;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 8;
Navy: Strength: 10;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 6;
Air Force: Strength: 8. 

Specialty: Executive Medicine[C];
Army: Requirement: 105;
Army: Authorized: 96;
Army: Strength: 0;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 58;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 123;
Air Force: Strength: 0. 

Specialty: Family Practice;
Army: Requirement: 575;
Army: Authorized: 458;
Army: Strength: 432;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 359;
Navy: Strength: 362;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 435;
Air Force: Strength: 473. 

Specialty: Gastroenterology;
Army: Requirement: 54;
Army: Authorized: 52;
Army: Strength: 57;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 18;
Navy: Strength: 21;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 20;
Air Force: Strength: 16. 

Specialty: General Medicine;
Army: Requirement: 0[D];
Army: Authorized: 0[D];
Army: Strength: 160[D];
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 461;
Navy: Strength: 263;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 3;
Air Force: Strength: 56. 

Specialty: General Surgery;
Army: Requirement: 246;
Army: Authorized: 229;
Army: Strength: 274;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 109;
Navy: Strength: 108;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 83;
Air Force: Strength: 87. 

Specialty: Graduate Medical Education (Post Graduate All Years);
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 1053;
Navy: Strength: 1072;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 896;
Air Force: Strength: 903. 

Specialty: Hematology/Oncology;
Army: Requirement: 41;
Army: Authorized: 40;
Army: Strength: 43;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 12;
Navy: Strength: 17;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 18;
Air Force: Strength: 14. 

Specialty: Infectious Disease;
Army: Requirement: 63;
Army: Authorized: 59;
Army: Strength: 62;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 29;
Navy: Strength: 34;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 16;
Air Force: Strength: 17. 

Specialty: Internal Medicine;
Army: Requirement: 315 [E];
Army: Authorized: 254 [E];
Army: Strength: 277 [E];
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 69;
Navy: Strength: 117;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 110;
Air Force: Strength: 142. 

Specialty: Nephrology;
Army: Requirement: 20;
Army: Authorized: 18;
Army: Strength: 20;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 9;
Navy: Strength: 8;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 10;
Air Force: Strength: 13. 

Specialty: Neurological Surgery;
Army: Requirement: 25;
Army: Authorized: 22;
Army: Strength: 17;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 14;
Navy: Strength: 21;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 9;
Air Force: Strength: 9. 

Specialty: Neurology;
Army: Requirement: 64[F];
Army: Authorized: 61[F];
Army: Strength: 63[F];
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 22;
Navy: Strength: 27;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 20;
Air Force: Strength: 29. 

Specialty: Nuclear Medicine;
Army: Requirement: 29;
Army: Authorized: 24;
Army: Strength: 21;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 1;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 1;
Air Force: Strength: 1. 

Specialty: Obstetrics/Gynecology;
Army: Requirement: 209;
Army: Authorized: 190;
Army: Strength: 219;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 98;
Navy: Strength: 120;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 81;
Air Force: Strength: 106. 

Specialty: Occupational Medicine;
Army: Requirement: 26;
Army: Authorized: 24;
Army: Strength: 24;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 34;
Navy: Strength: 33;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 7;
Air Force: Strength: 13. 

Specialty: Oncology Surgery;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 5;
Navy: Strength: 10;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 4;
Air Force: Strength: 3. 

Specialty: Ophthalmology;
Army: Requirement: 90;
Army: Authorized: 82;
Army: Strength: 100;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 40;
Navy: Strength: 48;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 26;
Air Force: Strength: 38. 

Specialty: Orthopedic Surgery;
Army: Requirement: 225;
Army: Authorized: 213;
Army: Strength: 243;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 117;
Navy: Strength: 117;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 83;
Air Force: Strength: 104. 

Specialty: Otorhinolaryngology;
Army: Requirement: 78;
Army: Authorized: 75;
Army: Strength: 87;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 42;
Navy: Strength: 56;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 21;
Air Force: Strength: 41. 

Specialty: Pathology;
Army: Requirement: 134;
Army: Authorized: 108;
Army: Strength: 118;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 57;
Navy: Strength: 65;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 53;
Air Force: Strength: 58. 

Specialty: Pediatric Surgery;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 6;
Navy: Strength: 4;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 1;
Air Force: Strength: 1. 

Specialty: Pediatrics, General;
Army: Requirement: 189;
Army: Authorized: 175;
Army: Strength: 165;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 56;
Navy: Strength: 67;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 146;
Air Force: Strength: 171. 

Specialty: Pediatrics, Subspecialties;
Army: Requirement: 82;
Army: Authorized: 80;
Army: Strength: 129;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 58;
Navy: Strength: 65;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 36;
Air Force: Strength: 66. 

Specialty: Peripheral Vascular Surgery;
Army: Requirement: 17;
Army: Authorized: 15;
Army: Strength: 20;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 10;
Navy: Strength: 10;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 6;
Air Force: Strength: 7. 

Specialty: Physical Rehabilitation Medicine;
Army: Requirement: 40;
Army: Authorized: 40;
Army: Strength: 52;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 3;
Navy: Strength: 3;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 0;
Air Force: Strength: 1. 

Specialty: Plastic Surgery;
Army: Requirement: 16;
Army: Authorized: 15;
Army: Strength: 18;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 9;
Navy: Strength: 10;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 11;
Air Force: Strength: 9. 

Specialty: Preventive Medicine;
Army: Requirement: 105;
Army: Authorized: 92;
Army: Strength: 84;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 47;
Navy: Strength: 38;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 20;
Air Force: Strength: 25. 

Specialty: Psychiatry;
Army: Requirement: 205[G];
Army: Authorized: 188[G];
Army: Strength: 180[G];
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 90;
Navy: Strength: 94;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 91;
Air Force: Strength: 102. 

Specialty: Pulmonary Disease;
Army: Requirement: 48;
Army: Authorized: 45;
Army: Strength: 44;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 18;
Navy: Strength: 34;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 23;
Air Force: Strength: 26. 

Specialty: Radiology, Diagnostic;
Army: Requirement: 223;
Army: Authorized: 184;
Army: Strength: 222;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 86;
Navy: Strength: 99;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 89;
Air Force: Strength: 135. 

Specialty: Radiology, Therapeutic;
Army: Requirement: 10;
Army: Authorized: 10;
Army: Strength: 18;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 8;
Navy: Strength: 11;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 8;
Air Force: Strength: 12. 

Specialty: Rheumatology;
Army: Requirement: 13;
Army: Authorized: 12;
Army: Strength: 15;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 5;
Navy: Strength: 7;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 8;
Air Force: Strength: 9. 

Specialty: Undersea Medicine;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 88;
Navy: Strength: 94;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 0;
Air Force: Strength: 0. 

Specialty: Urology;
Army: Requirement: 75;
Army: Authorized: 65;
Army: Strength: 71;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 28;
Navy: Strength: 27;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 18;
Air Force: Strength: 24. 

Specialty: Comprehensive Dentistry;
Army: Requirement: 204;
Army: Authorized: 200;
Army: Strength: 204;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 124;
Navy: Strength: 139;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 233;
Air Force: Strength: 230. 

Specialty: Endodontics;
Army: Requirement: 48;
Army: Authorized: 48;
Army: Strength: 61;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 41;
Navy: Strength: 43;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 24;
Air Force: Strength: 28. 

Specialty: Executive Dentistry [C];
Army: Requirement: 68;
Army: Authorized: 60;
Army: Strength: 0;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 13;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 31;
Air Force: Strength: 0. 

Specialty: General Dentistry;
Army: Requirement: 282;
Army: Authorized: 272;
Army: Strength: 247;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 578;
Navy: Strength: 496;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 296;
Air Force: Strength: 335. 

Specialty: Graduate Dental Education;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 131;
Navy: Strength: 110;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 163;
Air Force: Strength: 166. 

Specialty: Oral Maxillofacial Surgery;
Army: Requirement: 78;
Army: Authorized: 77;
Army: Strength: 99;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 77;
Navy: Strength: 74;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 39;
Air Force: Strength: 45. 

Specialty: Oral Pathology;
Army: Requirement: 11;
Army: Authorized: 11;
Army: Strength: 11;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 17;
Navy: Strength: 16;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 5;
Air Force: Strength: 5. 

Specialty: Orthodontics;
Army: Requirement: 30;
Army: Authorized: 30;
Army: Strength: 35;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 15;
Navy: Strength: 16;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 31;
Air Force: Strength: 34. 

Specialty: Pedodontics;
Army: Requirement: 24;
Army: Authorized: 24;
Army: Strength: 22;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 11;
Navy: Strength: 16;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 15;
Air Force: Strength: 20. 

Specialty: Periodontics;
Army: Requirement: 47;
Army: Authorized: 46;
Army: Strength: 54;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 41;
Navy: Strength: 47;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 50;
Air Force: Strength: 51. 

Specialty: Prosthodontics;
Army: Requirement: 55;
Army: Authorized: 54;
Army: Strength: 72;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 64;
Navy: Strength: 56;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 49;
Air Force: Strength: 48. 

Specialty: Public Health Dentistry;
Army: Requirement: 5;
Army: Authorized: 4;
Army: Strength: 5;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 3;
Navy: Strength: 6;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 2;
Air Force: Strength: 3. 

Specialty: Community Health Nurse;
Army: Requirement: 89;
Army: Authorized: 87;
Army: Strength: 119;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 0;
Navy: Strength: 21;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 0;
Air Force: Strength: 0. 

Specialty: Critical Care Nurse;
Army: Requirement: 426;
Army: Authorized: 419;
Army: Strength: 442;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 311;
Navy: Strength: 297;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 345;
Air Force: Strength: 416. 

Specialty: Emergency/Trauma Nurse;
Army: Requirement: 111;
Army: Authorized: 107;
Army: Strength: 142;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 161;
Navy: Strength: 201;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 189;
Air Force: Strength: 227. 

Specialty: Family Nurse Practitioner;
Army: Requirement: 156;
Army: Authorized: 145;
Army: Strength: 143;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 78;
Navy: Strength: 87;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 64;
Air Force: Strength: 63. 

Specialty: Flight Nurse;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 4;
Navy: Strength: 2;
Air Force: Requirement[B]: [Empty];
Air Force: Authorized: 190;
Air Force: Strength: 100. 

Specialty: General Nursing;
Army: Requirement: 143;
Army: Authorized: 131;
Army: Strength: 0;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 1240;
Navy: Strength: 479;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 0;
Air Force: Strength: 0. 

Specialty: Medical/Surgical Nurse;
Army: Requirement: 1141;
Army: Authorized: 1047;
Army: Strength: 1654;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 437;
Navy: Strength: 619;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 1516;
Air Force: Strength: 1560. 

Specialty: Mental Health Nurse;
Army: Requirement: 55;
Army: Authorized: 47;
Army: Strength: 61;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 43;
Navy: Strength: 63;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 30;
Air Force: Strength: 32. 

Specialty: Mental Health Nurse Practitioner;
Army: Requirement: 22;
Army: Authorized: 21;
Army: Strength: 27;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 9;
Navy: Strength: 17;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 15;
Air Force: Strength: 16. 

Specialty: Neonatal Intensive Care Unit Nurse;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 29;
Navy: Strength: 23;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 66;
Air Force: Strength: 52. 

Specialty: Nurse Anesthetist;
Army: Requirement: 249;
Army: Authorized: 225;
Army: Strength: 140;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 205;
Navy: Strength: 203;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 130;
Air Force: Strength: 135. 

Specialty: Nurse Education;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 64;
Navy: Strength: 46;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 71;
Air Force: Strength: 53. 

Specialty: Nurse Midwife;
Army: Requirement: 41;
Army: Authorized: 38;
Army: Strength: 36;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 26;
Navy: Strength: 29;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 20;
Air Force: Strength: 20. 

Specialty: Nurse Service Administration;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 59;
Navy: Strength: 212;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 225;
Air Force: Strength: 0. 

Specialty: Obstetrics Nurse;
Army: Requirement: 176;
Army: Authorized: 152;
Army: Strength: 173;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 133;
Navy: Strength: 239;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 250;
Air Force: Strength: 277. 

Specialty: Operating Room Nurse;
Army: Requirement: 266;
Army: Authorized: 259;
Army: Strength: 249;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 274;
Navy: Strength: 237;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 237;
Air Force: Strength: 219. 

Specialty: Pediatric Nurse Practitioner;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 28;
Navy: Strength: 28;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 34;
Air Force: Strength: 25. 

Specialty: Women's Health Nurse Practitioner;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 13;
Navy: Strength: 11;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 69;
Air Force: Strength: 81. 

Specialty: Veterinary;
Army: Requirement: 327;
Army: Authorized: 304;
Army: Strength: 361;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 0;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 0;
Air Force: Strength: 0. 

Specialty: Audiology and Speech;
Army: Requirement: 36;
Army: Authorized: 32;
Army: Strength: 31;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 18;
Navy: Strength: 18;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 40;
Air Force: Strength: 41. 

Specialty: Biochemistry;
Army: Requirement: 85;
Army: Authorized: 58;
Army: Strength: 84;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 33;
Navy: Strength: 36;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 7;
Air Force: Strength: 2. 

Specialty: Bioenvironmental Engineering;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 0;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 352;
Air Force: Strength: 362. 

Specialty: Clinical Laboratory;
Army: Requirement: 79;
Army: Authorized: 73;
Army: Strength: 111;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 67;
Navy: Strength: 78;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 153;
Air Force: Strength: 177. 

Specialty: Dietician;
Army: Requirement: 105;
Army: Authorized: 90;
Army: Strength: 133;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 22;
Navy: Strength: 30;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 41;
Air Force: Strength: 58. 

Specialty: Entomology;
Army: Requirement: 46;
Army: Authorized: 40;
Army: Strength: 44;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 33;
Navy: Strength: 38;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 14;
Air Force: Strength: 16. 

Specialty: Environmental Health;
Army: Requirement: 88;
Army: Authorized: 84;
Army: Strength: 142;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 80;
Navy: Strength: 78;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 189;
Air Force: Strength: 182. 

Specialty: Health Services Administration;
Army: Requirement: 1033;
Army: Authorized: 827;
Army: Strength: 700;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 1263;
Navy: Strength: 988;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 1027;
Air Force: Strength: 1030. 

Specialty: Industrial Hygiene;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 102;
Navy: Strength: 116;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 14;
Air Force: Strength: 7. 

Specialty: Microbiology;
Army: Requirement: 62;
Army: Authorized: 46;
Army: Strength: 75;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 43;
Navy: Strength: 50;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 10;
Air Force: Strength: 9. 

Specialty: Nuclear Medical Science;
Army: Requirement: 46;
Army: Authorized: 43;
Army: Strength: 43;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 64;
Navy: Strength: 71;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 10;
Air Force: Strength: 1. 

Specialty: Occupational Therapy;
Army: Requirement: 59;
Army: Authorized: 50;
Army: Strength: 83;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 19;
Navy: Strength: 21;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 19;
Air Force: Strength: 16. 

Specialty: Optometry;
Army: Requirement: 86;
Army: Authorized: 83;
Army: Strength: 107;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 106;
Navy: Strength: 115;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 133;
Air Force: Strength: 132. 

Specialty: Other Biomedical Officer;
Army: Requirement: 61;
Army: Authorized: 53;
Army: Strength: [Empty];
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 0;
Navy: Strength: 0;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 100;
Air Force: Strength: 0. 

Specialty: Pharmacy;
Army: Requirement: 139;
Army: Authorized: 123;
Army: Strength: 130;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 116;
Navy: Strength: 115;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 253;
Air Force: Strength: 233. 

Specialty: Physical Therapy;
Army: Requirement: 157;
Army: Authorized: 142;
Army: Strength: 214;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 67;
Navy: Strength: 78;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 133;
Air Force: Strength: 145. 

Specialty: Physician Assistant;
Army: Requirement: 184;
Army: Authorized: 151;
Army: Strength: 278;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 212;
Navy: Strength: 166;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 277;
Air Force: Strength: 292. 

Specialty: Physiology;
Army: Requirement: [Empty]; 
Army: Authorized: [Empty]; 
Army: Strength: [Empty]; 
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 91;
Navy: Strength: 108;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 115;
Air Force: Strength: 120. 

Specialty: Podiatry;
Army: Requirement: 24;
Army: Authorized: 20;
Army: Strength: 24;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 20;
Navy: Strength: 15;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 17;
Air Force: Strength: 15. 

Specialty: Psychology, Clinical;
Army: Requirement: 76;
Army: Authorized: 66;
Army: Strength: 131;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 133;
Navy: Strength: 129;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 255;
Air Force: Strength: 215. 

Specialty: Psychology, Non-Clinical;
Army: Requirement: 23;
Army: Authorized: 17;
Army: Strength: 19;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 45;
Navy: Strength: 47;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 0;
Air Force: Strength: 0. 

Specialty: Social Work;
Army: Requirement: 109;
Army: Authorized: 97;
Army: Strength: 131;
Navy: Requirement[A]: [Empty]; 
Navy: Authorized: 27;
Navy: Strength: 22;
Air Force: Requirement[B]: [Empty]; 
Air Force: Authorized: 191;
Air Force: Strength: 213. 

Source: DOD data. 

[A] Navy does not have a validated process for developing medical 
personnel requirements, so GAO is not reporting requirements for Navy. 

[B] Air Force does not currently have medical personnel requirements 
by specialty but is developing manpower standards for future use. 

[C] Executive positions are administrative and are filled by personnel 
from the other specialties listed. 

[D] Army's general medical personnel are no longer tracked on manning 
documents. End strength represents interns filling the specialty. 

[E] Navy and Air Force calculated Internal Medicine by adding 
Internist and Clinical Pharmacologist; we have done the same with 
Army's data. 

[F] Navy and Air Force calculated Neurology by adding Neurologist and 
Child Neurologist; we have done the same with Army's data. 

[G] Navy and Air Force calculated Psychiatry by adding Psychiatrist 
and Child Psychiatrist; we have done the same with Army's data. 

[End of table] 

[End of section] 

Appendix III: Comments from the Department of Defense: 

Department of Defense:
Office Of The Assistant Secretary Of Defense: 
Health Affairs: 
Washington, DC 20301-1200: 

July 19, 2010: 

Ms. Brenda S. Farrell: 
Director, Defense Capabilities and Management: 
U.S. Government Accountability Office: 
441 G. Street, N.W. 
Washington, DC 20548: 

Dear Ms. Farrell: 

This is the Department of Defense response to GAO #351382 Draft Report 
"Military Personnel: Enhanced Collaboration and Process Improvements 
Needed for Determining Military Treatment Facility Medical Personnel 
Requirement," (GAO-10696, GAO Code #351382) dated June 18, 2010. 

We agree with the GAO findings and recommendations discussed in the 
report. We have provided suggested technical corrections which we feel 
should be included in the final version. The present personnel 
requirements system, while not perfect and not uniform across all 
three Military Departments, does allow new requirements to be 
developed and adequately reflects each Military Department's needs. 

Thank you for the opportunity to review and comment on the Draft 
Report and for meeting with Mr. Middleton and senior representatives 
on June 29, 2010. Our comments on the recommendations and some 
technical corrections are addressed in the attached. 

My points of contact on this issue are Mr. Michael Hopper (Functional) 
at (703) 681-1698 and Mr. Gunther Zimmerman (Audit Liaison) at (703) 
681-4360. 

Sincerely, 

Signed by: 

Charles L. Rice, M.D. 
President, Uniformed Services University of the Health Sciences: 
Performing the Duties of the Assistant Secretary of Defense (Health 
Affairs): 

Enclosures: As stated: 

[End of letter] 

GAO Draft Report — Dated 18 June 2010: 
(GAO Code-351382/GA0-10-696): 

"Military Personnel: Enhanced Collaboration And Process Improvements 
Need For Determining Military Treatment Facility Medical Personnel 
Requirements" 

Department Of Defense Response To The Recommendations: 

Consistent with DoD emphasis on developing human capital solutions 
across the services to enable department wide decision making and 
analyses within its Military Health System, we recommend that the 
Secretary of Defense direct the Assistant Secretary of Defense for 
Health Affairs and the Service Secretaries to: 

Recommendation 1: Identify the common medical capabilities that are 
shared across the services in their military treatment facilities that 
would benefit from the development of cross-service medical manpower 
standards. 

DoD Response: Partially Concur. This review can be accomplished 
however must include a cost-benefit analysis before making any 
determination to develop cross-Service medical manpower standards. If 
there is not a significant, measurable benefit in cost, quality or 
access to medical care, then it would not be prudent to expend 
Department medical funds on such activities. 

Recommendation 2: Where applicable, develop and implement cross-
service medical manpower standards for those common medical 
capabilities. 

DoD Response: Concur. Developing cross-Service manpower standards in 
specific medical functional areas, where there is measurable benefit 
to the Department and/or the patient, makes good sense. This is what 
has been done in Mental Health, for instance. 

Recommendation 3: The GAO recommends that the Secretary of the Army 
direct the Army Surgeon General to update assumptions and other key 
data elements contained within specialty modules of the Army Staffing 
Assessment model. (See page 21 /GAO Draft Report.) 

DoD Response: Concur. Army will continue to update the Automated 
Staffing Assessment Model (ASAM). 

Recommendation 4: The GAO recommends that the Secretary of the Army 
direct the Army Surgeon General to develop and implement a definitive 
re-validation schedule for the specialty modules of the Army Staffing 
Assessment model. (Sec page 21/GAO Draft Report.) 

DoD Response: Concur. This will be closely coordinated between MEDCOM 
and the US Army Manpower Analysis Agency. 

Recommendation 5: The GAO recommends that the Secretary of the Army 
direct the Army Surgeon General to include its reliance on civilian 
medical personnel in its assumptions as it updates and validates their 
medical personnel requirements determination modules. (See page 21/GAO 
Draft Report.) 

DoD Response: Partially Concur. 58% of MEDCOM's workforce is civilian. 
Civilian contribution to the generation of medical workload will 
continue to be captured by the ASAM to ensure accurate medical 
manpower requirements determination in Army military treatment 
facilities. 

Recommendation 6: The GAO recommends that the Secretary of the Navy 
direct the Navy Surgeon General to develop a validated and verifiable 
process to determine its medical manpower requirements. (See page 
21/GAO Draft Report.) 

DoD Response: Partially concur. Approximately two years ago Navy 
Medicine initiated a comprehensive effort to address and redefine how 
medical manpower requirements were determined to meet the operational 
and MTF requirements. In conjunction with this effort the
Navy Surgeon General directed the development and validation of a 
requirements model. Initial delivery of the prototype model for 
testing and validation is expected by Fall 2010 and validation 
&verification efforts will commence at that time. 

Recommendation 7: The GAO recommends that the Secretary of the Navy 
direct the Navy Surgeon General to include its reliance on civilian 
medical personnel in its assumptions as it develops, and then 
validates, its medical personnel requirements determination model. 
(See page 21 /GAO Draft Report) 

DoD Response: Partially concur. The Navy Surgeon General, in 
evaluating medical personnel requirements, has always taken a Total 
Force approach to include not just Active Duty, but also Reserve, 
Civilian and Contract Personnel. The Navy Surgeon General will 
continue with this emphasis in all future planning and programming for 
medical personnel. 

Recommendation 8: The GAO recommends that the Secretary of the Air 
Force direct the Air Force Surgeon General to develop a validated and 
verifiable process to determine its medical manpower requirements, 
(See page 21/GAO Draft Report) 

DoD Response: Concur. On [0 May 2010, a Memorandum of Agreement 
between the Air Force Medical Service (AFMS) and the Air Force 
Manpower Agency (AFMA) was finalized whereby AFMA will develop new 
manpower standards for all AFMS product lines, The AFMA Flight that 
will develop these standards activates on I July 2010 and will 
initiate the first manpower studies on or about 1 August 2010. This 
flight will be collocated with the Air Force Medical Operations Agency 
(AFMOA) ensuring that manpower engineers obtain the most current 
information from those subject matter experts in the specific area of 
study. 

Recommendation 9: The GAO recommends that the Secretary of the Air 
Force direct the Air Force Surgeon General to include its reliance on 
civilian medical personnel in its assumptions as it develops, and then 
validates, its medical personnel requirements determination model. 
(See page 21/GAO Draft Report) 

DoD Response: Partially Concur. AFMS manpower standards being 
developed by AFMA include the identification of civilian equivalents 
for those positions that are not deemed military essential. This 
allows the AFMS to substitute civilians based on requirements and is 
based on Critical Operational Readiness Requirement (CORR). Civilian 
requirements arc also reviewed and determined through the Inherently 
Governmental/Commercial Activity process. The AFMS recently modified 
the Family Practice manpower model where civilian medical personnel 
are an integral part of the mission which is the case for each work 
center throughout the AFMS. 

Table 1: Strategic Collaboration On Medical Personnel Requirements: 

The Military Health System (MHS) strategic intention in workforce 
planning is to improve integration and interoperability between the 
human capital functions of the Services and HA/TMA by providing 
collaborative human capital direction. The 2007 MHS Human Capital	
Strategic Plan states "we maintain and respect our Service specific 
doctrines, we support joint missions and need to continue to develop 
our workplace capabilities to succeed in those environments." The 
Human Capital Strategic Plan remains a key document; a refresh will be	
released July 2010. The following examples illustrate recent 
collaborative efforts. 

* Patient-Centered Medical Home (PCMH). PCMH is a collaboratively 
developed model of Primary Care to improve continuity of care and 
enhance access through patient-centered care. There have been 
transparent discussions on staffing ratios, enrollment ratios and 
other planning factors. 

* Psychological Health Risk-Adjusted Model for Staffing (PITRAMS). The 
culmination of a collaborative manpower requirements effort from Army, 
Air Force, and Navy and ASD/HA and TMA, PHRAMS is a standardized 
evidence-based staffing model to ensure consistency in mental health 
staffing. The PHRAMS application will be used by the Services for 
program and workforce planning for the FY 2012-2017 Program Objective 
Memorandum. 

* Joint Task Force Capital Medicine (JTF CAPMED). The JTF CAPMED is a 
collaborative effort to transform, realign, and significantly enhance 
military healthcare in the National Capital Region (NCR) today and in 
the future by establishing jointly manned medical facilities. There is 
a unique opportunity to integrate processes to achieve economies of 
scale, eliminate redundancies, enhance clinical care and improve other 
functions and capabilities. 

* Strategic Analysis Working Group (SAWG). The SAWG is a collaborative 
forum for planning and programming medical requirements for 
operational missions. The SAWG, with each Service and Combatant 
Command Representative as members, supports both the planning and 
programming processes. The SAWG encourages the use of similar tools, 
data, software and models to determine operational medical 
requirements. 

* Proposed legislation for Financial Assistance for Health Professions-
Civilian. This proposed legislation was developed collaboratively with 
the Services to provide scholarships to civilian medical providers, 
similar to the highly successful scholarship program in-place for 
military providers. The goal is to improve recruiting and retention of 
civilian medical providers in the military healthcare system. 

* Title 38 Task Force. With the repeal of the National Security 
Personnel System (NSPS), DoD needs pay flexibility and ability to 
offer competitive salaries to adequately recruit and compensate 
civilian employees in critical healthcare occupations. Collaborative 
efforts across the Services and HA/TMA resulted in commitment to use 
Title 38 authorities to facilitate the transition of 30 healthcare 
occupations out of NSPS by 31 December, 2011. 

[End of table] 

[End of section] 

Appendix IV: GAO Contacts and Staff Acknowledgments: 

GAO Contact: 

Brenda S. Farrell, (202) 512-3604 or farrellb@gao.gov: 

Acknowledgments: 

In addition to the individual named above, David Moser (Assistant 
Director), Rebecca Beale, Chaneé Gaskin, Randy Neice, Cheryl Weissman, 
Michael Willems, and Elizabeth Wood made key contributions to this 
report. 

[End of section] 

Footnotes: 

[1] DOD provides medical care for its active duty servicemembers, 
retirees, and their eligible dependents through its TRICARE program. 
TRICARE brings together the health care resources of the Army, Navy, 
and Air Force and supplements them with networks of civilian health 
care providers. TRICARE offers three options--Prime, Extra, and 
Standard. Depending on which option is chosen, active duty 
servicemembers and their families may pay no enrollment fees and may 
have little or no deductibles or cost shares. Retirees (under 65), 
their families, and all other beneficiaries may have to pay annual 
enrollment fees and/or cost shares based on where they receive care. 

[2] Amount in fiscal year 2000 dollars. Using medical cost conversion 
factors, this amount would equal $30.8 billion in fiscal year 2010 
dollars. 

[3] GAO, Defense Health Care: Issues and Challenges Confronting 
Military Medicine, [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-95-104] (Washington, D.C.: March 
22, 1995). 

[4] GAO, 21st Century Challenges: Reexamining the Base of the Federal 
Government, [hyperlink, http://www.gao.gov/products/GAO-05-325SP] 
(Washington, D.C.: February 2005). 

[5] GAO, Defense Health Care: DOD Needs to Address the Expected 
Benefits, Costs, and Risks for Its Newly Approved Medical Command 
Structure, [hyperlink, http://www.gao.gov/products/GAO-08-122] 
(Washington, D.C.: Oct. 12, 2007). 

[6] S. Rep. No 110-335, at 353 (2008). 

[7] GAO, Military Personnel: Status of Accession, Retention, and End 
Strength for Military Medical Officers and Preliminary Observations 
Regarding Accession and Retention Challenges, [hyperlink, 
http://www.gao.gov/products/GAO-09-469R] (Washington, D.C.: April 16, 
2009). 

[8] We anticipate issuing a report on medical personnel requirements 
in support of contingency operations in Iraq and Afghanistan later 
this year. 

[9] For purposes of this report, the Assistant Secretary of Defense 
for Health Affairs will be referred to as Health Affairs. 

[10] Department of Defense Directive 5136.01, Assistant Secretary of 
Defense for Health Affairs (Jun. 4, 2008). 

[11] 10 U.S.C. § 3013(c)(5), 10 U.S.C. § 5013(c)(5), and 10 U.S.C. § 
8013(c)(5). 

[12] The U.S. Navy provides all of the medical care for the U.S. 
Marine Corps. 

[13] Military Health System Human Capital Strategic Plan for 2008-2013 
(Nov. 2007). 

[14] Department of Defense Directive 5000.59, DOD Modeling and 
Simulation Management, § 5.7.3 (Aug. 8, 2007). 

[15] Military Base Realignments and Closures: Estimated Costs Have 
Increased While Savings Estimates Have Decreased Since Fiscal Year 
2009, [hyperlink, http://www.gao.gov/products/GAO-10-98R] (Washington, 
D.C.: November 13, 2009). 

[16] Department of Defense Directive 5000.59, § 5.7.3 (Aug. 8, 2007). 

[17] In providing technical comments to a draft of this report, DOD 
noted it has made progress in the past few years towards joint 
unitization of personnel, such as tri-service staffed hospitals in 
Kuwait and Iraq; the establishment of a human capital office at the 
Health Affairs level for providing coordination and assistance to the 
services in establishing a joint human capital strategy for civilian 
personnel; tri-service team to develop special pay structures for 
medical professionals; and the development of two information 
management systems used by all three military departments to establish 
more standardized data and data sharing among the services. While we 
recognize these efforts as examples of cross-service collaboration, 
they are not directly related to the medical personnel requirements 
determination process for fixed military treatment facilities, which 
is the focus of this report. 

[18] Department of Defense Directive 1100.4, Guidance for Manpower 
Management, § 3.2 (Feb. 12, 2005). 

[19] Department of Defense Instruction 5000.61, DOD Modeling and 
Simulation Verification, Validation, and Accreditation (Dec. 9, 2009). 

[20] Department of Defense Directive 1100.4, § 3.2.3 (Feb. 12, 2005). 

[21] Section 721 of the National Defense Authorization Act for Fiscal 
Year 2008, Pub. L. No. 110-181 (2008) (as amended by section 701 of 
the National Defense Authorization Act for Fiscal Year 2010, Pub. L. 
No. 111-84 (2009)) prohibits the secretaries of the military 
departments from converting any military medical positions to civilian 
medical positions during the period beginning on or after October 1, 
2007. 

[22] The Department of Defense's Fiscal Year 2009 Status Report on the 
Implementation of the Department's Strategic Civilian Human Capital 
Plan 2006-2010, March 31, 2010. 

[End of section] 

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