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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

June 2011: 

Defense Centers Of Excellence: 

Limited Budget and Performance Information on the Center for 
Psychological Health and Traumatic Brain Injury: 

GAO-11-611: 

GAO Highlights: 

Highlights of GAO-11-611, a report to congressional requesters. 

Why GAO Did This Study: 

The National Defense Authorization Act for Fiscal Year 2008 
established the Defense Centers of Excellence for Psychological Health 
and Traumatic Brain Injury (DCOE) in January 2008 to develop 
excellence in prevention, outreach, and care for service members with 
psychological health (PH) conditions and traumatic brain injury (TBI). 
DCOE consists of six directorates and five component centers that 
carry out a range of PH- and TBI-related functions. GAO was asked to 
report on (1) DCOE’s budget formulation process; and (2) availability 
of information to Congress on DCOE. 

GAO reviewed budget guidance, budget requests and performance data. 
GAO reviewed Department of Defense (DOD) reports submitted to Congress 
on PH and TBI and interviewed DOD officials. 

What GAO Found: 

DCOE’s role in the DOD budget formulation process is limited. For 
fiscal year 2012, DCOE’s role in budget formulation was limited to 
consolidating component center budget requests and providing budget 
requests to TMA. Further, the budget requests DCOE provided to TMA did 
not have complete narrative justifications. Office of Management and 
Budget Circular A-11 specifies that the basic requirements for a 
justification include a description of the means and strategies used 
to achieve performance goals. At the time of GAO’s review, prior-year 
funding and obligations data and funding received by component centers 
from sources external to DCOE were not readily available. The absence 
of these data indicates that TMA and DCOE did not have benefit of this 
data to inform budget formulation decisions. Also, quarterly reviews 
conducted by DCOE that collect data on performance and resources do 
not include component centers. Expansion of reviews and greater access 
to performance information could provide DCOE an opportunity to 
collect information that links component center performance with 
resources and better informs budget decision making. 

DCOE’s mission and funding have not been clearly defined to Congress. 
At a congressional hearing, Members expressed differing visions of 
DCOE’s mission and voiced concern about the amount of time needed to 
establish DCOE and achieve results. Moreover, in four congressional 
subcommittee testimonies, DCOE’s first director and the Assistant 
Secretary of Defense for Health Affairs characterized DCOE as DOD’s 
“open front door for all concerns related to PH and TBI.” These 
statements suggest a divergent understanding of DCOE’s role and 
bolster the importance of clear communication on DCOE’s mission, 
funding, and activities. 

Because DCOE is a relatively small entity primarily funded through the 
larger Defense Health Program appropriation, it falls below the most 
detailed level that is presented in congressional budget presentation 
materials. In addition, at Congress’s request DOD provides mandated 
and ad hoc reports on PH and TBI expenditures. While these reports 
present information on activities and accomplishments for PH and TBI, 
DOD does not—and is not required to—report separately on DCOE. 

What GAO Recommends: 

To enhance visibility and improve accountability, GAO recommends that 
the Secretary of Defense direct the Director of TRICARE Management 
Activity (TMA) work with the Director of DCOE to develop and use 
additional narrative in budget justifications, to regularly collect 
and review data on funding and obligations, and expand its review and 
analysis process. DOD concurred with GAO’s recommendations. GAO 
understands that the expanded review and analysis process would not 
include realigned component centers. GAO agrees that ensuring entities 
external to TMA comply with regular collections of funding and 
obligations data could be a limitation. 

View [hyperlink, http://www.gao.gov/products/GAO-11-611] or key 
components. For more information, contact Denise M. Fantone at (202) 
512-6806 or fantoned@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

While DCOE's Role in the Budget Formulation Process Is Limited, More 
Complete Information Would Be Helpful: 

Limited Information Is Available on DCOE's Mission, Funding, and 
Activities: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Description of Defense Centers of Excellence for 
Psychological Health and Traumatic Brain Injury Directorates and 
Component Centers: 

Appendix III: Comments from the Department of Defense: 

Appendix IV: GAO Contacts and Staff Acknowledgments: 

Table: 

Table 1: Selected DOD Reports to Congress on PH and TBI Activities: 

Figures: 

Figure 1: DCOE Headquarters and Component Centers Alignment within DOD: 

Figure 2: Beginning of Fiscal Year 2010 Allotment of DHP Operations 
and Maintenance PH and TBI Funding Across DOD, Including DCOE and DCOE 
Component Centers: 

Figure 3: Flow of PH and TBI Funds to DCOE and Component Centers: 

Abbreviations: 

CDP: Center for Deployment Psychology: 

CSTS: Center for the Study of Traumatic Stress: 

DCOE: Defense Centers of Excellence for Psychological Health and 
Traumatic Brain Injury: 

DHCC: Deployment Health Clinical Center: 

DHP: Defense Health Program: 

DOD: Department of Defense: 

DVBIC: Defense and Veterans Brain Injury Center: 

NDAA: National Defense Authorization Act for Fiscal Year 2008: 

NICOE: National Intrepid Center of Excellence: 

PH: psychological health: 

POM: Program Objective Memorandum: 

RDT&E: Research, Development, Test and Evaluation: 

T2: National Center for Telehealth and Technology: 

TBI: traumatic brain injury: 

TMA: TRICARE Management Activity: 

TMA FOD: TRICARE Management Activity Financial Operations Division: 

USUHS: Uniformed Services University of the Health Sciences: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

June 30, 2011: 

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

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

As of June 2011, approximately 44,000 U.S. military service members 
have been wounded in action in conflicts in Afghanistan and Iraq. Due 
to improved battlefield medicine, those who might have died in past 
conflicts are now surviving, many with multiple serious injuries---
such as amputations, burns, and traumatic brain injuries--that require 
extensive outpatient rehabilitation. Congress passed the National 
Defense Authorization Act for Fiscal Year 2008, which directed the 
Department of Defense (DOD) to create centers of excellence on 
traumatic brain injury (TBI) and post-traumatic stress disorder and 
other psychological health (PH) conditions to develop excellence in 
the prevention, outreach, and care for those with PH and TBI 
conditions.[Footnote 1] In fiscal year 2010 DOD allotted $638 million 
in operations and maintenance funding for PH and TBI activities; of 
these funds, the Defense Centers of Excellence for Psychological 
Health and Traumatic Brain Injury (DCOE) and its component centers 
received about $168 million[Footnote 2]. Congressional committees have 
expressed concerns about how DCOE formulates its budget. 

This is the second report we are issuing about DCOE's establishment 
and ongoing development. We issued a report in February 2011 examining 
DCOE's strategic planning and financial management.[Footnote 3] In 
that report we recommended the Secretary of Defense direct DCOE to 
improve its strategic plan by aligning daily activities in support of 
goals and improving performance measures to enable DCOE to determine 
if achievement of each measure fully supports attainment of its 
associated goal. In addition, we recommended that the Director of the 
TRICARE Management Activity (TMA)--under which DCOE operates--
develops, updates, and maintains written procedures for proper 
classification and recording of DCOE obligations. DOD concurred with 
our recommendations. 

For this report, we were asked to examine DCOE's budget formulation 
process and the availability of its funding and performance 
information to Congress. In particular, we addressed the following 
objectives: 

1. Describe and evaluate DCOE's budget formulation within the broader 
DOD-wide budget process for PH and TBI and the information used to 
make budget decisions. 

2. Evaluate the information available to Congress on DCOE's funding 
and activities. 

To achieve these objectives, we reviewed DCOE's budget formulation for 
operations and maintenance funding for fiscal years 2008 through 2012. 
To understand DCOE's budget formulation process and the data used to 
inform budget requests, we reviewed documentation relevant to its 
budget formulation process and interviewed knowledgeable DOD 
officials. To understand DCOE's structure, history, and funding, we 
gathered and analyzed information on the creation and organization of 
DCOE. We also reviewed the legislative history of DCOE, DOD 
appropriations acts, and accompanying committee reports. We 
interviewed officials at Health Affairs, TMA, the Uniformed Services 
University of the Health Sciences (USUHS), DCOE, and DCOE's component 
centers about the budget formulation process, and the information used 
in budget decision making. We reviewed DCOE's mission, strategic 
goals, and performance measures. Also, we reviewed budget request and 
justification documents for DCOE and its component centers. To 
understand how DCOE participates in DOD budget formulation processes, 
we reviewed DOD budget formulation guidance, including guidance 
specifically affecting DCOE or PH and TBI. 

To determine what information is available to Congress on DCOE's 
funding and activities we reviewed the President's budget requests and 
DOD justification documents for relevant years and reports requested 
by Congress on DOD's effort to address PH and TBI. To identify 
congressional direction on information requirements, we reviewed DOD 
appropriations acts, accompanying committee reports, and congressional 
hearing records. 

We conducted this performance audit from June 2010 through June 2011 
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: 

The National Defense Authorization Act for Fiscal Year 2008 (NDAA) 
directed DOD to establish centers of excellence for traumatic brain 
injury and post-traumatic stress disorder. Although the NDAA described 
responsibilities for the centers, it did not specify where the centers 
should be located within the DOD organization. Instead, it directed 
the Secretary of Defense to ensure that to the maximum extent 
practicable centers collaborate with governmental, private, and 
nonprofit entities. Senior-level DOD officials[Footnote 4] convened 
representatives from the Army, Navy, Air Force, Marines, and 
Department of Veterans Affairs to determine how to establish the 
centers. Informally, this group was known as the "Red Cell" and its 
primary mission was to address recommendations related to PH and TBI. 
[Footnote 5] Rather than establishing separate centers of excellence 
for traumatic brain injury and post-traumatic stress disorder, a 
combined center for both PH and TBI was created. According to one 
representative, the Red Cell also debated how funding would be divided 
between PH and TBI and across the military services. The military 
services, TMA, and DCOE receive PH and TBI funding through the Defense 
Health Program (DHP) appropriation account. 

DOD Organizational Structure and the DCOE Network: 

Organizationally the services are led by Secretaries who have a direct 
relationship with the Secretary of Defense. As shown in figure 1, DCOE 
reports directly to the Assistant Secretary of Defense for Health 
Affairs/Director of TMA within the Office of the Secretary of Defense. 

Figure 1: DCOE Headquarters and Component Centers Alignment within DOD: 

[Refer to PDF for image: illustration] 

Top level: 
Office of the Secretary of Defense: 
* Army; 
* Navy; 
* Air Force; 
* Under Secretary of Defense for Personnel and Readiness; 
* Assistant Secretary of Defense (Health Affairs)/Director of TRICARE 
Management Activity. 

Second level: 
DCOE (Headquarters office): 
* Director; 
* Executive Steering Committee; 
* Support staff (Resource management, human resources, facilities 
management). 

DCOE Directorates: 
* Strategic Communications Directorate; 
* Education Directorate; 
* Research Directorate; 
* Psychological Health Clinical Standards of Care Directorate; 
* Resilience and Prevention Directorate; 
* Traumatic Brain Injury Clinical Standards of Care Directorate. 

Third level: 
DCOE (Component Centers): 
* Defense and Veterans Brain Injury Center; Established: 1992; 
* Deployment Health Clinical Center; Established: 1994; 
* Center for the Study of Traumatic Stress; Established: 1987; 
* Center for Deployment Psychology; Established: 2006; 
* National Center for Telehealth and Technology; Established: 2008. 

Source: GAO analysis of Department of Defense documents. 

[End of figure] 

DCOE consists of a central office and six directorates. The central 
office conducts multiple functions such as leadership and resource 
management and is responsible for DCOE's budget formulation process. 
The six directorates carry out a range of activities related to PH and 
TBI, including operating a call center, disseminating information on 
DOD training programs, developing clinical practice guidelines related 
to PH and TBI, and identifying PH and TBI research needs. The DCOE 
network also includes five component centers[Footnote 6] that provide 
an established body of knowledge and experience related to PH and TBI. 
The component centers are the Defense and Veterans Brain Injury Center 
(DVBIC), Deployment Health Clinical Center (DHCC), Center for the 
Study of Traumatic Stress (CSTS), Center for Deployment Psychology 
(CDP), and the National Center for Telehealth[Footnote 7] and 
Technology (T2). 

PH and TBI Funding and Allotments: 

Over time, PH and TBI funding evolved from DHP amounts directed 
specifically for PH and TBI to funding support being incorporated into 
the broader DHP appropriation. In fiscal year 2007, Congress 
appropriated approximately $600 million specifically for TBI and post- 
traumatic stress disorder treatment.[Footnote 8] In fiscal year 2008, 
Congress specifically appropriated $75 million for PH and TBI 
activities.[Footnote 9] In fiscal year 2009, funding for PH and TBI 
was not appropriated a specific amount, rather funding was drawn from 
DHP's general operation and maintenance funds--DOD had discretion over 
the amount and distribution of funds internally allotted.[Footnote 10] 
Beginning in fiscal year 2010, PH and TBI funding was included in the 
base budget request for the DHP, which established a longer-term 
funding stream for PH and TBI.[Footnote 11] 

As shown in figure 2, in fiscal year 2010 a total of $638 million in 
DHP operations and maintenance funding was allotted for PH and TBI 
across the military services, TMA Financial Operations Division (TMA 
FOD), and DCOE. The Army received the largest portion of funds, about 
$279 million or 44 percent, while DCOE received approximately $168 
million or 26 percent. Of all PH and TBI funding allotted, $96 million 
or 15 percent was suballoted to component centers within the DCOE 
network.[Footnote 12] 

Figure 2: Beginning of Fiscal Year 2010 Allotment of DHP Operations 
and Maintenance PH and TBI Funding Across DOD, Including DCOE and DCOE 
Component Centers: 

[Refer to PDF for image: pie-chart and subchart] 

Army: $279 million; 
DCOE: $168 million; 
Navy: $104 million; 
TMA FOD: $64.6 million; 
Air Force: $22.2 million. 

DCOE subchart: 
DCOE HQ: $72 million; 
DVBIC: $31.8 million; 
T2: $21.9 million; 
NICOE: $20.3 million; 
CDP: $8.5 million; 
DHCC: $8.3 million; 
CSTS: $5.2 million. 

Source: GAO presentation of Department of Defense data. 

Notes: 

Because of unresolved concerns with the reliability of funding and 
obligations data provided by DOD, we cannot confirm the accuracy of 
figures related to DCOE. 

Figures do not include funds allotted from the DHP Research, 
Development, Test and Evaluation appropriation account for PH and TBI 
activities. In fiscal year 2010, Army, Air Force, and Navy were 
allotted Research, Development, Test and Evaluation funds. Army 
received approximately $179 million, the Air Force received 
approximately $900 thousand, and the Navy received approximately $16 
million. 

[End of figure] 

DOD Budget Formulation Process: 

Budget formulation for DOD occurs as part of the Planning, 
Programming, Budgeting and Execution Process, which projects near-term 
defense spending. The system is intended to provide defense decision 
makers with the data they need to make trade-offs among potential 
alternatives; thus resulting in the best possible mix of forces, 
equipment, and support to accomplish DOD's mission. Specifically, DOD 
budget formulation occurs in the programming phase of the Planning, 
Programming, Budgeting and Execution Process, and begins with the 
development of a program objective memorandum (POM). The POM reflects 
decisions about resource allocations and proposed budget estimates and 
is used to inform the development of the President's Budget and DOD 
Congressional Justifications. Because DCOE is only one, relatively 
small entity receiving funds through the broader DHP appropriation, it 
is not visible in DOD budget presentation materials. The POM covers 
six fiscal years and is developed in even fiscal years, for example 
fiscal year 2008 and fiscal year 2010.[Footnote 13] DOD develops the 
POM approximately 18 months in advance of the first fiscal year the 
POM covers. 

While DCOE's Role in the Budget Formulation Process Is Limited, More 
Complete Information Would Be Helpful: 

DCOE Does Not Make PH and TBI Budget Formulation Decisions, and Its 
Input to the Process Is Limited: 

DCOE had a limited role in budget decision making for the fiscal year 
2012 POM process. Ultimately, senior DOD officials,[Footnote 14] 
including the Health Affairs Deputy Assistant Secretaries of Defense, 
decided to fund 1 of 18 PH and TBI requests, which did not include 
DCOE's. For this POM, DCOE headquarters solicited and received budget 
requests from component centers. Ultimately, DCOE accepted and 
incorporated all component center requests into its budget request. 
However, in some instances DCOE officials said they requested 
additional justification from component centers. PH and TBI budget 
requests from across DOD, including DCOE, were collected for 
consideration in the fiscal year 2012 POM. A working group of PH and 
TBI subject matter experts within DOD reviewed and prioritized 
requests for funding above the fiscal year 2010 base budget from 
across the department. According to a DCOE official, DCOE's interests 
were represented by TMA officials who contributed to the 
prioritization of these requests; however, the final decisions were 
not formally communicated to DCOE. 

DCOE had a limited role in budget formulation for the fiscal year 2010 
POM[Footnote 15] because it was still in its first year of operation. 
According to a senior DOD official, no limits were imposed on PH and 
TBI budget requests and no trade-off decisions were made. 
Nevertheless, this year was significant because it was the first year 
that DCOE's budget was considered in the DHP baseline budget request. 
According to DCOE officials, because DCOE had only recently been 
established, it had limited staff. In addition, component centers were 
still being realigned under DCOE and both the relationship between 
component centers and DCOE and the missions of two component centers, 
T2 and the National Intrepid Center of Excellence (NICOE), were 
unclear. For the fiscal year 2008 POM process, the newly established 
DCOE had no role in budget formulation. Instead, the Red Cell convened 
to determine how the centers of excellence would be implemented and 
provided recommendations on DCOE's original budget, which the Senior 
Oversight Committee approved.[Footnote 16] Because the POM process 
occurred on a biannual basis in even fiscal years, DOD did not have a 
budget formulation process in fiscal years 2009 and 2011. 

DCOE's Budget Request Did Not Have Complete Narrative Justification: 

For the fiscal year 2012 POM, DCOE provided limited narrative support 
for its budget justification. TMA requested that DCOE complete and 
submit a spreadsheet template with cost estimates and narrative for 
resource requests above the prior-year baseline. The narrative portion 
asked for four elements: (1) background, (2) requirements summary, (3) 
impact to other programs, and (4) the risk if not funded. DCOE and its 
component centers did not provide this template in a complete manner. 
Not all of the requested narrative elements were provided. For 
example, the impact to other programs was not discussed for half the 
requests DCOE submitted.[Footnote 17] In addition, the DCOE 
headquarters request was calculated with a 3.5 percent inflation 
factor versus the 1.7 percent prescribed in POM guidance, but DCOE did 
not explain why it needed to use a higher inflation rate. 

Two years earlier, for the 2010 POM, DCOE provided no narrative 
support for its budget justification. TMA requested that DCOE provide 
completed spreadsheets that did not include a narrative component. For 
this POM, DCOE differentiated the amounts it requested by PH or TBI 
strategic initiatives and by commodity,[Footnote 18] but did not 
provide narrative justifications for these amounts. Guidance contained 
in OMB Circular A-11 specifies that the basic requirements for a 
justification include a description of the means and strategies used 
to achieve performance goals. Means can include human resources, 
information technology, and operational processes. Strategies may 
include program, policy, management, regulatory, and legislative 
initiatives and approaches and should be consistent with the agency's 
improvement plans.[Footnote 19] According to OMB, a thorough 
description of the means and strategies to be used will promote 
understanding of what is needed to achieve a certain performance level 
and increase the likelihood that the goal will be achieved. To develop 
a comprehensive departmentwide budget submission to OMB, a thorough 
description of means and strategies in justifications is needed at all 
levels within an agency. 

DCOE already collects information that could improve its budget 
justifications. DCOE requests that both directorates and component 
centers prepare "fact sheets," which contain detailed information 
including mission, activities, relevant legislation, staffing, 
performance metrics, and resource requirements.[Footnote 20] 
Information like that in the fact sheets provides an expanded 
discussion of performance information. DCOE and TMA could leverage 
this existing information to improve budget justifications and 
resulting decisions. 

Key Information Was Not Readily Available to Inform Budget Formulation: 

Decision making for DCOE's budget formulation could be facilitated by 
key information, such as funding and obligations data, additional non- 
DCOE funding received by its component centers, and performance 
information resulting from internal reviews. This information could 
also help DCOE justify and prioritize its budget requests. However, 
DOD required more than 3 months to query numerous sources and provide 
us with prior-year data on funding and obligations for DCOE and its 
component centers. The absence of readily available, comprehensive 
historical funding and obligations data indicates that TMA and DCOE 
did not have benefit of these data to inform budget formulation. 
Furthermore, DCOE and TMA FOD do not have access to systems that track 
funds authorized for execution on behalf of the DCOE component centers 
because component center budget execution is conducted at multiple 
sites that maintain separate financial systems. According to TMA and 
DCOE officials, DCOE has limited responsibility for budget execution 
activities. TMA FOD and DCOE must request and compile obligations data 
for funds administrated by budget execution sites. For example, as 
shown in figure 3, once DCOE requests that TMA FOD authorize funding 
for T2, the funds are provided to T2's host entity, Madigan Army 
Medical Center. At this point, TMA and DCOE can no longer monitor the 
execution of T2's funds through TMA's financial reporting systems and 
must request that information. TMA FOD's financial system contains 
data on spending it administrates for DCOE headquarters and component 
centers. DCOE and TMA should use comprehensive historical funding and 
obligations data to inform budget formulation and justify requests. 
OMB Circular A-11 directs agencies to present prior-year resource 
requirements in budget justification materials. 

Figure 3: Flow of PH and TBI Funds to DCOE and Component Centers: 

[Refer to PDF for image: illustration] 

Office of the Undersecretary of Defense Comptroller: 

TMA Program Budget and Execution Office: 

TMA Financial Operations Division[A]: 
DCOE Headquarters (DCOE financial management input to TMA). 

Madigan Army Medical Center[A]: 
T2. 

Uniformed Services University of the Health Sciences[A]: 
CSTS; 
CDP. 

Walter Reed Army Medical Center[A]: 
DHCC; 
DVBIC. 

Source: GAO presentation of Department of Defense data. 

[A] Budget execution site. 

[End of figure] 

Prior to our review, DCOE did not collect information on the sources 
and amounts of funds component centers received in addition to 
allotments from DCOE, and therefore did not have benefit of these data 
to help inform budget decision making.[Footnote 21] In some cases, 
component centers receive significant amounts of non-DCOE funding. For 
example, Deployment Health Clinical Center received about $8.3 million 
in funding from DCOE in fiscal year 2010, while it was awarded about 
$3.3 million from external sources.[Footnote 22] Standards for 
internal control in the federal government state that information 
should be recorded and communicated to management and others within 
the entity who need it[Footnote 23]. Without information on non-DCOE 
funding, when DCOE and TMA make trade-off decisions, they cannot 
consider all the resources available to component centers. While DCOE 
has begun collecting information on component centers' non-DCOE 
funding, it has not had an opportunity to use that data to inform 
budget formulation and requests because the fiscal year 2012 POM 
process already occurred. 

Additionally, DCOE could obtain more performance information to better 
prioritize and justify its budget requests. In the middle of fiscal 
year 2010, DCOE began to hold quarterly meetings to evaluate 
directorates' performance and reallocate resources used for DCOE's 
daily activities.[Footnote 24] However, component centers are not 
included in this process. A DCOE official said component centers are 
excluded because DOD is reviewing the governance structure of all DOD 
centers of excellence, and this could affect the organizational 
structure of DCOE.[Footnote 25] But if DCOE included the component 
centers in this process, it could collect information that links 
component center performance with resources and enhance future budget 
decision making. 

Limited Information Is Available on DCOE's Mission, Funding, and 
Activities: 

DCOE's mission has not been clearly defined to Congress. For example, 
in one hearing of the House Committee on Armed Services,[Footnote 26] 
Members expressed differing visions of DCOE's mission. One Member 
expressed frustration that DCOE had not become an "information 
clearinghouse" and the "preeminent catalog of what research has been 
done," as had been envisioned. A second Member described his vision of 
DCOE being an overarching body that "coordinates, inspects, and 
oversees the tremendous amount of good work being done across the 
nation." Members also voiced concern about the amount of time needed 
to establish DCOE and achieve results. In four congressional 
subcommittee testimonies, DCOE's first director and the Assistant 
Secretary of Defense for Health Affairs characterized DCOE as DOD's 
"open front door for all concerns related to PH and TBI."[Footnote 27] 
These statements suggest a divergent understanding of DCOE's role and 
bolster the importance of clear communication on DCOE's mission, 
funding, and activities. 

DCOE is a relatively small entity and it does not typically appear in 
DOD DHP budget presentation materials and falls below the most 
detailed level that is presented--the Budget Activity Group level. 
[Footnote 28] DCOE has only appeared in DOD's budget presentation 
materials for fiscal year 2010, when PH and TBI funding was first 
included in the DHP base budget request.[Footnote 29] In the request, 
DOD did not specify that DCOE's individual budget request for 2010 was 
only about $168 million[Footnote 30] of the $800 million requested. 
Specifically, the request stated "$0.8B to fund operations of the 
Defense Center of Excellence (DCoE) for Psychological Health and 
Traumatic Brain Injury, and to ensure that critical wartime medical 
and health professionals are available to provide needed mental health 
services by improving hiring and retention bonuses and offering 
targeted special pay." 

DOD provides supplemental reporting on PH and TBI expenditures through 
reports mandated in the National Defense Authorization Act for Fiscal 
Year 2008, as well as ad hoc reports at Congress's request. While 
these reports present activities and accomplishments by strategic 
initiative, DOD is not required to separately report on DCOE in its 
annual reports. Thus, while PH and TBI information is reported to 
congressional decision makers, DCOE specific funding and activities 
are not visible. The Government Performance Results Act (GPRA) 
Modernization Act of 2010[Footnote 31] further requires agencies to 
consult with the congressional committees that receive their plans and 
reports to determine whether they are useful to the committee. Table 1 
summarizes selected mandated and ad hoc reports DOD provided to 
Congress. 

Table 1: Selected DOD Reports to Congress on PH and TBI Activities: 

Report title: Comprehensive Plan on Prevention, Diagnosis, Mitigation, 
Treatment, and Rehabilitation of, and Research on, Traumatic Brain 
Injury, Post-Traumatic Stress Disorder, and other Mental Health 
Conditions in Members of the Armed Forces; 
Report details: 
Mandate: NDAA 2008 Section 1618b; 
Reporting Frequency: Once; 
Date Provided to Congress: October 2008; 
Report content: Summarized DOD's program to address PH and TBI needs, 
including program capabilities by strategic initiative. Outlined 
DCOE's focus areas and described gaps in DCOE's capabilities at the 
time. 

Report title: Report on the Establishment of the Centers of Excellence; 
Report details: 
Mandate: NDAA 2008 Section 1624; 
Reporting Frequency: Once; 
Date Provided to Congress: November 2008. 
Report content: Described the background, mission, and structure of 
DCOE. Assessed DCOE's progress, plans, and objectives with examples of 
DCOE collaborations and activities by strategic initiative. 

Report title: Annual Report on TBI and Post-Traumatic Stress Disorder 
Expenditures; 
Report details: 
Mandate: NDAA 2008 Section 1634b; 
Reporting Frequency: Annually through 2013; 
Dates Provided to Congress: May 2008; June 2010[A]; 
Report content: Described activities, PH and TBI DOD priorities, and a 
progress assessment; Reported expenditures for DVBIC; all other 
expended funds are listed by DOD-wide strategic initiatives, not by 
entity. 

Report title: Senate Appropriations Committee reports; 
Mandate: n/a; 
Reporting Frequency: Monthly; 
Dates Provided to Congress: Provided monthly in 2009; 
Report content: Displayed expenditures by strategic initiative, budget 
activity group, and commodity[B] for PH and TBI activities within the 
DHP. 

Source: GAO analysis of reports provided to Congress by DOD. 

[A] DOD did not provide an annual expenditure report to Congress in 
2009. 

[B] DOD commodities include Civilian Pay, Contracts, Equipment, 
Pharmacy, Supplies, Travel, and Other. 

[End of table] 

Conclusions: 

DCOE faces numerous challenges, such as recruiting staff and shaping 
relationships with its component centers and military services. 
Nonetheless, DCOE could take additional steps to make better informed 
budget decisions and justify resource requests. DCOE lacks key 
information, such as comprehensive funding and obligations data for 
component centers and does not make full use of performance data. 
Better leveraging of such information could enhance DCOE's ability to 
influence component centers' progress towards achievement of positive 
outcomes for wounded service members. For DCOE to achieve its mission 
and goals it must have access to and consider information needed to 
prioritize its activities and communicate its role to stakeholders. As 
DOD reviews the governance structure of its centers of excellence, 
such as DCOE, it has an opportunity to ensure that these centers have 
the tools needed to promote success. 

Recommendations for Executive Action: 

To enhance visibility and improve accountability, we recommend that 
the Secretary of Defense direct the Director of TMA to work with the 
Director of DCOE on the following three actions: 

1. develop and use additional narrative, such as that available in 
component center fact sheets, in budget justifications to explain the 
means and strategies that support the request. 

2. establish a process to regularly collect and review data on 
component centers' funding and obligations, including funding external 
to DCOE. 

3. expand its review and analysis process to include component centers. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to the Secretary of the Department 
of Defense for official review and comment. The Assistant Secretary of 
Defense of Health Affairs and Director of TRICARE Management Activity 
provided us with written comments, which are summarized below and 
reprinted in appendix III. DOD also provided technical comments that 
were incorporated into the report as appropriate. DOD concurred with 
all of our recommendations. Specifically, DOD concurred with our 
recommendation that the Director of TRICARE Management Activity (TMA) 
work with the Director of the Defense Centers of Excellence for 
Psychological Health and Traumatic Brain Injury (DCOE) to develop and 
use additional narrative, such as that available in component centers' 
fact sheets and budget justifications. DOD also concurred with our 
recommendation to establish a process to regularly collect and review 
data on component centers' funding and obligations, including funding 
external to DCOE. However, DOD stated that one limitation in executing 
this recommendation is ensuring entities external to TMA comply with 
the request to regularly report funding and obligations data. We agree 
that this limitation presents challenges for DCOE's and TMA's 
oversight of obligations and funding data. However, a complete 
understanding of this information is important to fully review the 
resources that affect DCOE's operations. 

DOD stated that DCOE is appropriately informed of budget execution 
data through formal systems, as well as informal coordination and 
managerial reporting. In addition, TMA stated that it executes a 
majority of the total operations and maintenance funding that DCOE and 
its component centers receive and that TMA, DCOE, and the Services 
have instituted numerous internal controls to monitor planned and 
actual expenditures. Despite the level of oversight described by DOD, 
it was not readily able to provide us with disaggregated information 
on DCOE's funding and obligations. Although TMA does execute and 
oversee the majority of operations and maintenance funding for DCOE 
and its component centers, additional funding remains outside of its 
oversight, including approximately 18 percent of operations and 
maintenance funding. 

The data provided for fiscal year 2010 remain incomplete and the 
information provided has not been sufficient to confirm its accuracy 
or reliability. Furthermore, DOD was unable to describe the process 
used to identify and resolve errors in source data from multiple 
financial systems, and TMA stated that it could not confirm the 
accuracy of data from financial systems it does not administrate. This 
raises questions about DCOE and TMA's oversight and use of these data 
to inform budget formulation. Lastly, DOD agreed with the 
recommendation to expand its review and analysis process to include 
component centers, but that it did not plan to include two component 
centers, the Center for the Study of Traumatic Stress and the Center 
for Deployment Psychology, which are in the process of formally 
aligning under the Uniformed Services University of the Health 
Sciences. 

We are sending copies of this report to the Secretary of Defense and 
appropriate congressional committees. In addition, the report is 
available at no charge on the GAO Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staffs have any questions about this report, please 
contact Denise M. Fantone at (202) 512-6806 or fantoned@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 major contributions to this report are listed in appendix IV. 

Signed by: 

Denise M. Fantone: 
Director, Strategic Issues: 

[End of section] 

Appendix I: Scope and Methodology: 

We reviewed the Defense Centers of Excellence for Psychological Health 
and Traumatic Brain Injury (DCOE) budget formulation for fiscal years 
2008 through 2012. To understand DCOE's budget formulation process and 
the data used to inform budget requests, we reviewed documentation 
relevant to its budget formulation process and interviewed 
knowledgeable Department of Defense (DOD) officials. To understand 
DCOE's structure, history, and funding, we gathered and analyzed 
information on the creation and organization of DCOE, such as the 
report on the outcomes of the Red Cell, and memorandums of agreement 
between DCOE and component centers. We also reviewed the legislative 
history of DCOE, DOD appropriations acts from fiscal years 2007, 2008, 
2009, and 2010, and accompanying committee reports. 

Initially, we sought to obtain funding and obligations data from 
fiscal years 2007 through 2011; however, DOD was unable to provide 
these data in a timely manner, and ultimately provided data that we 
determined were not sufficiently reliable for presenting funding and 
obligations figures. As a result, the team reduced the scope of our 
data request to only include fiscal year 2010. Through interviews and 
responses to written questions, DOD provided additional information 
about the process used to generate and validate this data. However, as 
of May 5, 2011, the data provided for fiscal year 2010 remain 
incomplete, and the information provided has not been sufficient to 
confirm the accuracy or reliability of all detailed funding and 
obligations data. Because such data are necessary to fully understand 
the budget process for psychological health (PH) and traumatic brain 
injury (TBI), the team decided to present these data, but to note that 
we have not confirmed their accuracy. 

We reviewed DCOE's mission, strategic goals, and performance measures. 
Also, we reviewed budget request and justification documents for DCOE, 
and its component centers for fiscal years 2010 and 2012, and 
documents that support the development of budget requests, such as 
component center fact sheets. To understand how DCOE participates in 
DOD budget formulation processes we reviewed DOD budget formulation 
guidance, including TRICARE Management Activity (TMA) and Program 
Objective Memorandum (POM) guidance for fiscal year 2010 and 2012 that 
specifically affects DCOE. The Defense Health Program appropriation 
includes three accounts, Operations and Maintenance, Procurement, and 
Research, Development, Test and Evaluation (RDT&E). We focused our 
review on the budget formulation process for Operations and 
Maintenance funding because DCOE and DCOE component centers do not 
receive any baseline funding for Procurement and RDT&E, which are 
obtained through separate budget processes. We interviewed officials 
at Health Affairs, Force Health, Protection and Readiness, TMA, the 
Uniformed Services University of the Health Sciences (USUHS), DCOE, 
and DCOE's component centers about the budget formulation process, and 
the information used in budget decision making. 

To determine what information is available to Congress on DCOE's 
funding and activities, we reviewed the President's budget requests 
and DOD's justification documents for fiscal years 2010, 2011, and 
2012. In addition, we reviewed reports mandated by the 2008 National 
Defense Authorization Act on PH conditions and TBI, and reports 
requested by the Senate Appropriations Committee on PH and TBI 
expenditures. To identify congressional direction on information 
requirements, we reviewed DOD appropriations acts from fiscal years 
2007, 2008, 2009, and 2010, accompanying committee reports, and 
congressional hearing records. 

We conducted this performance audit from June 2010 through June 2011 
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: Description of Defense Centers of Excellence for 
Psychological Health and Traumatic Brain Injury Directorates and 
Component Centers: 

Six directorates carry out a range of activities related to 
psychological health (PH) conditions and traumatic brain injury (TBI). 

Directorates include: 

* Strategic Communications Directorate--To strategically inform and 
disseminate to multiple audiences and stakeholders; providing relevant 
and timely information, tools, and resources for warriors, families, 
leaders, clinicians, and the community that empowers them, supports 
them, and strengthens their resilience, recovery, and reintegration. 

* Psychological Health Clinical Standards of Care Directorate--To 
promote optimal clinical practice standards to maximize the 
psychological health of warriors and their families. 

* Research Directorate--To improve PH and TBI outcomes through 
research; quality programs and evaluation; and surveillance for our 
service members and their families. 

* Resilience and Prevention Directorate--Assist the military services 
and the DOD to optimize resilience; psychological health; and 
readiness for service members, leaders, units, families, support 
personnel, and communities. 

* Education Directorate--To assess training and educational needs in 
order to identify, and promote effective instructional material for 
stakeholders resulting in improved knowledge and practice of PH and 
TBI care. 

* Traumatic Brain Injury Clinical Standards of Care Directorate--To 
develop state of the science clinical standards to maximize recovery 
and functioning and to provide guidance and support in the 
implementation of clinical tools for the benefit of all those who 
sustain traumatic brain injuries in the service of our country. 

The Defense Centers of Excellence for Psychological Health and 
Traumatic Brain Injury (DCOE) network also includes five component 
centers[Footnote 32] that provide an established body of knowledge and 
experience related to PH and TBI. Component centers include: 

* Defense and Veterans Brain Injury Center (DVBIC)--With a focus on 
TBI, DVBIC was created as a collaboration between DOD and Department 
of Veterans Affairs that serves military personnel, veterans, and 
their families by providing clinical care, conducting research, and 
providing education and training to DOD providers. 

* Deployment Health Clinical Center (DHCC)--Focused on deployment- 
related health concerns, including PH, DHCC serves military personnel, 
veterans, and their families by providing outpatient care, conducting 
research, leading the implementation of a primary care screening 
program for post-traumatic stress disorder and depression, and 
information to military health system providers. 

* Center for the Study of Traumatic Stress (CSTS)--By addressing a 
wide scope of trauma exposure that includes the psychiatric 
consequences of war, deployment, disaster, and terrorism, CSTS serves 
DOD, and collaborates with federal, state, and private organizations. 
Activities include conducting research, providing education and 
training to military health system providers, and providing 
consultation to government and other agencies on preparedness and 
response to traumatic events. 

* Center for Deployment Psychology (CDP)--Covering both PH and TBI, 
CDP trains military and civilian psychologists and other mental health 
professionals to provide high quality deployment-related behavioral 
health services to military personnel and their families. 

* National Center for Telehealth[Footnote 33] and Technology (T2)-- 
Addressing both PH and TBI, T2 serves military personnel, veterans, 
and their families by acting as the central coordinating agency for 
DOD research, development, and implementation of technologies for 
providing enhanced diagnostic, treatment, and rehabilitative services. 

[End of section] 

Appendix III: Comments from the Department of Defense: 

Note: GAO comments supplementing those in the report text appear at 
the end of this appendix. 

The Assistant Secretary Of Defense: 
Health Affairs: 
1200 Defense Pentagon: 
Washington, DC 20301-1200: 

June 3, 2011: 

Ms. Denise Fantone: 
Director, Strategic Issues: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Dear Ms. Fantone: 

This is the Department of Defense (DoD) response to the Government 
Accountability Office (GAO) Draft Report, GA0-11-611, "Limited Budget 
and Performance Information on the Center for Psychological Health 
(PH) and Traumatic Brain Injury (TBI)," received on May 13, 2011, (GAO 
Code #450844). Overall, I concur with recommendations made in the 
draft report. I would like to clarify some information, however, in 
order to better describe financial controls and processes currently in 
place to support the Defense Centers of Excellence (DCoE) for PH and 
TBI budget activities. First, I would like to emphasize the components 
of DCoE's budget formulation and execution processes that support 
thoughtful investment decisions, as well as accountability and 
reliability in managerial data collection. Second, in preparation for 
the Fiscal Year (FY) 2010 Program Objective Memorandum (POM) and the
Future Years Defense Budget (FYDP), DCoE has been involved fully in 
program justification within the DoD system. Finally, DCoE has 
maintained open and responsive communications with Congress in 
reference to its ongoing achievements in the field of PH and TBI. 

DCoE is a new organization, established in FY 2008 with an initial 
PH/TBI Operations and Management (O&M) budget of $45 million. DCoE's 
program requirements and corresponding budget growth in FY 2009-2010 
were informed by existing projects, as well as proposed activities in 
compliance with legislative and task force guidance. A baseline 
funding plan was established during the FY 2010 program review ($180 
million in O&M dollars). Formulation of the budget and FYDP, by DCoE 
staff, followed established Department and Military Health System 
guidance, including review and endorsement by the Senior Military 
Medical Advisory Council consisting of the Service Surgeons General. 
The program review and budget process have been followed by DCoE since 
the establishment of the base budget. 

While DCoE does not have a standalone financial system, TMA oversight 
of obligations and expenditures has kept the DCoE Director 
appropriately informed of budget execution data. This information has 
been reported through formal systems, as well as informal coordination 
and managerial reporting between TMA Program Budget and Execution, TMA 
Financial Operations Division (FOD), DCoE, and the Uniformed Services 
University of the Health Sciences (USUHS). In fact, in FY 2010 TMA FOD 
executed 82 percent ($137 million) of the total O&M funding identified 
for DCoE and its CCs. Adding the USUHS data ($21 million in funding 
authorization documents (FADs)), a total of 5158 million (94 percent) 
of DCoE and its CC FY 2010 PH/TBI O&M funding are auditable at the TMA 
leveL In addition, DCoE, TMA, and the Services have instituted 
numerous internal controls to monitor planned and actual expenditures 
covering the remaining 6 percent of support costs. With respect to 
Research Development Test and Evaluation (RDT&E) appropriations, grant 
dollars arc separately reviewed, distributed, and accounted for 
outside of TMA. While central oversight of RDT&E activities could be 
improved, it is important to note that the DCoE portfolio was not 
originally structured to manage DCoE CC research projects. [See 
comment 1] 

In relation to the reliability of DCoE/TMA funding data (Figure 2 in 
Draft Report), DCoE took the time to verify obligation and FAD data so 
that all responses were auditable with regard to the $168 million 
reported. Recently, TMA FOD was audited as part of GAO engagement
#290826 for all FY 2009 DCoE obligations. For the current audit, the 
process of collecting and providing information was complex and 
lengthy. The data call was a dual request for audit engagements 
#450844 and #351513, including all appropriations data (O&M, RDT&E, 
and procurement) from multiple sources within DoD (e.g., Services, 
TMA, and USUHS) for FY 2007-2010. Although the GAO sought a singular 
DoD representative for this data, the report was a coordinated effort 
due to the segmentation of financial systems. Given the complexity, 
several meetings were held during the audit to clarify the data call 
request to ensure that DCoE and GAO defined terms in the same way. As 
a result of guidance from GAO, DCoE submitted revised versions of the 
funding spreadsheet to ensure GAO received the information according 
to their specific business rules. DCoE acknowledges that this was a 
lengthy process but is confident in the reliability of the information 
provided to GAO. [See comment 2] 

Finally, as the report included several comments in regard to DCoE's 
relationship with Congress, it is important to note that DCoE, since 
its inception, has worked to inform Members of Congress about its 
mission. The information shared was refined in accordance with DCoE's 
organizational growth and maturity. DCoE has continued to make subject 
matter experts available to Members upon request to discuss such 
topics as TBI, PH, and overall DCoE activities. In 2011, DCoE 
leadership met with several congressional committees, using the 
opportunity to clarify DCoE's role and obtain input from congressional 
stakeholders to better align expectations. 

Thank you for the opportunity to review and provide comments. The 
points of contact on this issue are Ms. Anne Giese (Functional) and 
Mr. Gunther Zimmerman (Audit Liaison). Ms. Giese may be reached at 
(301) 295-3687 or Anne.Giese@tma.osd.mil. Mr. Zimmerman may be reached 
at (703) 6814360 or Gunther.Zitnmerman@tma.osd.mil. 

Signed by: 

Jonathan Woodson, M.D. 

Enclosures: As stated. 

[End of letter] 

GAO Draft Report Dated May 13, 2011: 
(GAO Code #450844/GA0-11-611): 

"Limited Budget And Performance Information On The Center For
Psychological Health And Traumatic Brain Injury" 

Department Of Defense Comments To The Recommendations: 

To enhance visibility and improve accountability, we recommend that 
the Secretary of Defense direct the Director of TRICARE Management 
Activity (1MA) to work with the Director of the Defense Centers of 
Excellence (DCoE) on the following three actions: 

Recommendation #1: Develop and use additional narrative, such as that 
available in Component Centers' fact sheets and in budget 
justifications, to explain the means and strategics that support the 
request. 

DOD Response: Concur. 

Recommendation #2: Establish a process to regularly collect and review 
data on Component Centers' funding and obligations, including funding 
external to DCoE. 

DOD Response: Concur. DCoE will develop a process to enhance its 
existing funding data collection for Component Centers, including 
funding external to DCoE. The only limitation in the execution of this 
recommendation is the degree to which the receiving entities outside of
TMA comply with the request to regularly report out on the funding and 
obligations data. 

Recommendation #3: Expand its review and analysis process to include 
Component Centers. 

DOD Response: Concur. DCoE will expand its current review and analysis 
process to include the Defense and Veterans Brain Injury Center, the 
Deployment Health Clinical Center, and the National Center for 
Telehealth and Technology. As the Center for the Study of Traumatic 
Stress and the Center for Deployment Psychology are in the process of 
formally aligning under Uniformed Services University of the Health 
Sciences, DCoE does not plan to include these two organizations in the 
review and analysis process at this time. 

Technical Comments: 

Page 9 (Paragraph 4). [Now on p. 3] The term "Senior level DoD 
officials" should refer to the Line of Action Two (LOA2) leads, not 
the Senior Oversight Committee (SOC). The SOC established the eight 
Lines of Action. Recommend re-wording the sentence and Footnote 4 to 
indicate the appropriate group. In addition, recommend clarifying the 
Red Cell's role, noting that its primary mission was to address 400-
plus recommendations related to Psychological Health (PH) and 
Traumatic Brain Injury (TBI), which included developing a conceptual 
framework for a Center of Excellence for PH and TBI. 

Page 10 (Paragraph 1). [Now on p. 4] In a Decision Memorandum, dated 
August 7, 2007, the SOC directed the Department of Defense (DoD) and 
Department of Veterans Affairs to establish a center of excellence no 
later than November 30, 2007. Recommend replacing "Red Cell" with 
"SOC," as they were the officials that directed the establishment of a 
combined center for PH and TBI. 

Page 11 (Figure 1). [Now on p. 5] In the chart, the first DCoE 
Directorate listed, "Strategic Management Directorate," is incorrect. 
Recommend replacing "Strategic Management Directorate" with
"Strategic Communications Directorate." 

Page 12 (Paragraph 2). [Now on p. 6] Regarding the reference to the 
"additional $75 million for PH and TBI activities" in FY 2008, this 
statement is incorrect. The $75 million was originally FY
2007/2008 appropriated funding subsequently rescinded and re-
appropriated in FY 2009. Recommend deleting the sentence referencing 
2008 dollars. Regarding the FY 2009 reference to Operations and 
Management (O&M) funds "without a specific amount," this statement 
also is incorrect. Recommend noting that FY 2009 Defense Health 
Program (DHP) O&M funds totaled $585 million, consisting of the $75 
million re-appropriated from FY 2007/2008, $300 million in 
supplemental funds, and $210 million in Congressional add-ons. 

Page 12 (Paragraph 3). [Now on p. 6] Regarding the "$638 million 
[that] was allotted for PH and TBI," recommend noting that this amount 
refers to O&M funding, as explained in Figure 2. 

Page 13 (Figure 2). In the chart, the dollar amounts listed for DCoE 
and its Component Centers are incorrect. Recommend changing the 
amounts listed in Figure 2: Beginning of Fiscal Year Allotment of 
Operations and Maintenance PH and TBI Funding as follows: the amount 
for DCoE should be listed as $180.2 million; the amount for the Center 
for the Study of Traumatic Stress (CSTS) should be listed as $5.2 
million; the amount for the Deployment Health Clinical Center (DHCC) 
should be listed as $9.8 million; the amount for the Center for
Deployment Psychology (CDP) should be listed as $5.7 million; the 
amount listed for the National Intrepid Center of Excellence(NICoE) 
should be listed as $21.7 million; the amount listed for the Center 
for Telehealth and Technology cr2) should be listed as $20.3 million; 
the amount listed for the Defense and Veterans Brain Injury Center 
(DVBIC) should be listed as $31.9 million; the amount listed for DCoE 
Headquarters (HQ) should be listed as $85.6 million. For additional 
background information, please refer to the original funding 
spreadsheet that was submitted to the GAO Strategic Issues Team by 
DCGE on February 15, 2011. [See comment 1] 

Page 15 (Paragraph 1). [Now on p. 9] DCoE does not have any evidence 
that the final decisions of the PH and TIM working group were 
published. Therefore, recommend changing the language to note that the 
final decisions were not "formally" communicated to DCoE. 

• Page 15 (Paragraph 2). [Now on p. 9] The Red Cell provided 
recommendations to the LOA2 leads as to how the FY 2008 PH/TB1 O&M 
dollars, a $600 million Congressional appropriation (page 12), should 
be allocated across DoD components, including the Services and DCoE. 
Their recommendations did not include an initial budget for DCoE, but 
rather suggested an initial portion, approximately $45 million, of the 
total $600 million. Final allocation decisions were made by the SOC. 
Recommend changing the existing language to note that the Red Cell did 
not form DCoE's original budget, but rather provided recommendations 
pertaining to DCoE's original O&M allocation for FY 2008. 

Page 20 (Paragraph 2). [Now on p. 14] DCoE did not appear in the DoD 
DHP budget presentation materials not because of its "small" size, but 
rather DoD Program Objective Memorandum materials are presented 
according to programs. 'Therefore, presentations arc not detailed out 
by organizations such as DCoE. Recommend noting that DCoE was not 
listed in the DoD DHP budget presentation materials, as these 
documents report out by program, not specific organizations. 

Page 21 (Paragraph 1). Per the technical comment for page 13 (Figure 
2), the $168 million noted in this sentence is incorrect. Recommend 
deleting "$168 million" or replacing "$168 million" with "$180.2 
million." [See comment 1] 

The following GAO comments on the Department of Defense's letter dated 
June 3, 2011, supplement those that appear in the text of the report. 

1. While DOD stated that DCOE is appropriately informed of budget 
execution data through formal systems, as well as informal 
coordination and managerial reporting, DOD was not readily able to 
provide us with basic information on funding and obligations. 
Furthermore, the data provided for fiscal year 2010 remain incomplete 
and the information provided has not been sufficient to confirm its 
accuracy and reliability. This raises questions about DCOE and TMA's 
oversight and use of these data to inform budget formulation. Accurate 
and reliable status of funding data should be used as the starting 
point to inform, justify, and prioritize future budget requests. 
Although DOD stated that funding data provided to us on February 15, 
2011, should be reported on, we continue to believe that these data do 
not reflect specific psychological health and traumatic brain injury 
funding that DCOE provided to component centers. Service-level data 
provided on that date were not subsequently revised. However, data for 
DCOE and its component centers were revised multiple times after 
receiving initial data on February 15, 2011. We continued to work with 
DCOE and TMA to address inconsistencies, incorporate new data, and 
establish a common understanding of budget terminology, such as 
allotments and obligations. Moreover, DOD provided numerous revisions 
to data provided after February 15, 2011, and continued to do so even 
in comments to the draft of this report. While DOD believes that the 
data provided are reliable, DOD was unable to describe the process 
used to identify and resolve errors in source data from multiple 
financial systems, and TMA stated that it could not confirm the 
accuracy of data from financial systems it does not administrate. 

[End of section] 

Appendix IV: GAO Contacts and Staff Acknowledgments: 

GAO Contact: 

Denise M. Fantone, (202) 512-6806 or fantoned@gao.gov: 

Acknowledgments: 

In addition to the individual listed above, Carol M. Henn, Assistant 
Director; Erinn L. Sauer; Michael Aksman; Alexandra Edwards; Robert 
Gebhart; Jyoti Gupta; Chelsa Gurkin; Felicia Lopez; and Steven Putansu 
made major contributions to this report. 

[End of section] 

Footnotes: 

[1] Psychological health conditions include post-traumatic stress 
disorder, which is a type of anxiety disorder that is triggered by a 
traumatic event. Traumatic brain injury is damage to the brain that 
may result from a violent blow or jolt to the head, or from an object 
penetrating the skull. 

[2] Because of unresolved concerns with the reliability of funding and 
obligations data provided by DOD, we cannot confirm the accuracy of 
figures related to DCOE. 

[3] GAO, Defense Health: Management Weaknesses at Defense Centers of 
Excellence for Psychological Health and Traumatic Brain Injury Require 
Attention, [hyperlink, http://www.gao.gov/products/GAO-11-219] 
(Washington, D.C.: February 28, 2011). 

[4] In May 2007, DOD and VA established the Senior Oversight Committee 
as a temporary, 1-year committee with the responsibility for 
addressing recommendations from multiple reports on a broad range of 
topics. To conduct its work, the Senior Oversight Committee 
established eight work groups. One work group of senior-level DOD 
officials focused specifically on issues related to TBI and post-
traumatic brain injury. For additional information on the Senior 
Oversight Committee and the work groups, see GAO, Recovering 
Servicemembers: DOD and VA Have Jointly Developed the Majority of the 
Required Policies but Challenges Remain, GAO-09-728 (Washington, D.C.: 
July 8, 2009). 

[5] The term "Red Cell" is normally used to denote the enemy forces in 
military war games. It was chosen for this group because the daunting 
task facing this team would likely make them the enemy of everyone 
else in the bureaucracy they sought to change. 

[6] Until August 2010, DCOE also included a sixth component center, 
the National Intrepid Center of Excellence (NICOE), but the center has 
since been realigned and is transitioning to the National Naval 
Medical Center. 

[7] Telehealth increases access to care through information and 
telecommunication technologies. 

[8] Pub. L. No. 110-28, 121 Stat. 119, 134 (May 25, 2007). The 
appropriations specified that the $600 million available for the 
treatment of traumatic brain injury and post-traumatic stress disorder 
was to remain available until September 30, 2008. 

[9] Pub. L. No. 110-252, 122 Stat. 2323, 2403 (June 30, 2008). Amounts 
appropriated for PH and TBI purposes remained available for two fiscal 
years, expiring September 30, 2009. 

[10] See Pub. L. No. 110-329, 122 Stat. 3574, 3617 (Sept. 30, 2008). 

[11] See Pub. L. No. 111-118, 123 Stat. 3424 (Dec. 19, 2009); Pub. L. 
No. 111-212, 124 Stat. 2310 (July 29, 2010). 

[12] Because of unresolved concerns with the reliability of funding 
and obligations data provided by DOD, we cannot confirm the accuracy 
of figures related to DCOE. 

[13] The multiyear POM process is used to develop the President's 
annual budget request. For the purposes of this report we refer only 
to the first year of the POM. Effective April 2010, the DOD began to 
implement the process annually. 

[14] The DOD senior officials are referred to as the Super Integrating 
Council. The Super Integrating Council is composed of Deputy Surgeons 
General of the Air Force, Navy and Army, and Commander Joint Task 
Force National Capital Region Medical Command, the Joint Staff 
Surgeon, and the Health Affairs Deputy Assistant Secretaries for 
Defense. 

[15] POM planning begins approximately 18 months prior to the start of 
the fiscal year. 

[16] The Senior Oversight Committee was established in May 2007 by DOD 
and VA as a temporary 1-year committee with the responsibility for 
addressing recommendations from multiple reports on a broad range of 
topics, including TBI and post-traumatic stress disorder. The 
committee is co-chaired by the Deputy Secretaries of DOD and VA and 
includes military service Secretaries and other high-ranking officials 
within both departments. According to DOD officials, although the 
Senior Oversight Committee was established as a temporary committee it 
remains in existence. 

[17] The DCOE request was comprised of a request for DCOE 
headquarters, DHCC, CSTS, CDP, T2, and DVBIC. 

[18] DOD strategic initiatives for PH and TBI include: access to care; 
quality of care; surveillance and screening systems; leadership and 
advocacy; resilience promotion; transition and coordination of care; 
and research. DOD commodities include Civilian Pay, Contracts, 
Equipment, Pharmacy, Supplies, Travel, and Other. 

[19] OMB Circular No. A-11, Preparation, Submission, and Execution of 
the Budget, pt. 2, § 51 (July 2010). 

[20] According to DCOE officials, fact sheets are updated at least 
once a year, although some component centers have chosen to update 
their fact sheets more frequently. 

[21] Component centers receive funds in addition to allotments from 
DCOE, such as through Congressionally Directed Medical Research 
Programs, the National Institutes of Mental Health and direct research 
funds provided by the Services. 

[22] Because of unresolved concerns with the reliability of funding 
and obligations data provided by DOD, we cannot confirm the accuracy 
of figures related to DCOE. 

[23] GAO, Internal Control: Standards for Internal Control in the 
Federal Government, [hyperlink, 
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.: 
November 1999). 

[24] GAO, Defense Health: Management Weaknesses at the Defense Centers 
of Excellence for Psychology Health and Traumatic Brain Injury Require 
Attention, [hyperlink, http://www.gao.gov/products/GAO-11-219] 
(Washington, D.C.: February 2011). 

[25] One DCOE official asserted that any expansion of the review and 
analysis process would most likely begin with component centers more 
closely aligned to DCOE headquarters, that is, DHCC, DVBIC, and T2. 
These three centers have established memorandums of agreement that 
define their relationship with DCOE. 

[26] Hearing on Department of Defense Medical Centers of Excellence, 
U.S. House Armed Services Committee, April 13, 2010. 

[27] Testimony by Colonel Loree K. Sutton, Special Assistant to the 
Assistant Secretary of Defense for Health Affairs for PH and TBI, 
before the Personnel Subcommittee of the U.S. Senate Armed Services 
Committee (Mar. 5, 2008), Findings and Recommendations of the 
Department of Defense Task Force on Mental Health, the Army's Mental 
Health Advisory Team Reports, and Department of Defense and Service- 
wide Improvements in Mental Health Resources, Including Suicide 
Prevention for Servicemembers and their Families; Testimony by The 
Honorable S. Ward Casscells, M.D., Assistant Secretary of Defense for 
Health Affairs, before the Subcommittee on Military Personnel, U.S. 
House Armed Services Committee, March 14, 2008, Military Health Issues 
(Mar. 14, 2008); Testimony by General Loree Sutton, Special Assistant 
to the Assistant Secretary of Defense for Health Affairs for PH and 
TBI, before the Defense Subcommittee of the U.S. House Appropriations 
Committee, March 3, 2009, Psychological Health and Traumatic Brain 
Injury Programs (Mar. 3, 2009); and Testimony by Loree K. Sutton, 
Director, Defense Centers of Excellence for Psychological Health and 
Traumatic Brain Injury, before the Personnel Subcommittee of the U.S. 
Senate Armed Services Committee, Testimony on the Incidence of 
Suicides of United States Servicemembers and Initiatives within the 
Department of Defense to Prevent Military Suicides (Mar. 18, 2009). 

[28] Examples of Budget Activity Groups include "In-House Care," 
"Consolidated Health Support," "Information Management," "Management 
Activities," "Education and Training," and "Base Operations 
Communications." 

[29] Future year funding for DCOE was mentioned explicitly for 
information technology projects under DHP's RDT&E account, totaling 
approximately $1 million for fiscal years 2011 and 2012. 

[30] Because of unresolved concerns with the reliability of funding 
and obligations data provided by DOD, we cannot confirm the accuracy 
of figures related to DCOE. 

[31] Pub. L. No. 111-352, § 11, 124 Stat. 3866, 3881-82 (Jan. 4, 2011). 

[32] Until August 2010, DCOE also included a sixth component center, 
the National Intrepid Center of Excellence (NICOE), but the center has 
since been realigned and is transitioning to the National Naval 
Medical Center. 

[33] Telehealth increases access to care through information and 
telecommunication technologies. 

[End of section] 

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