Defense Health Care: Actions Needed to Determine the Required Size and Readiness of Operational Medical and Dental Forces

What GAO Found

The Department of Defense (DOD) has not determined the required size and composition of its operational medical and dental personnel who support the wartime mission or submitted a complete report to Congress, as required by the National Defense Authorization Act for Fiscal Year 2017. Leaders from the Office of the Secretary of Defense (OSD) disagreed with the military departments' initial estimates of required personnel that were developed to report to Congress. OSD officials cited concerns that the departments had not applied assumptions for operating jointly in a deployed environment and for leveraging efficiencies among personnel and units. GAO found that the military departments applied different planning assumptions in estimating required personnel, such as the definition of “operational” requirements. DOD expects to provide its next update to Congress in February 2019. Until DOD establishes joint planning assumptions for developing medical and dental personnel requirements, including a definition, and a method to assess options for achieving joint efficiencies, DOD will not know whether it has the optimal requirements to achieve its missions.

DOD has begun initiatives to maintain the critical wartime readiness of medical providers. DOD's initiatives have included standardizing and expanding pre-deployment training and developing new policy on medical provider readiness. In addition, department leaders have been directing transformation efforts to improve readiness. However, DOD's methodology is limited with respect to a key initiative that will use a metric to assess medical providers' clinical readiness—a component of wartime readiness. Specifically:

DOD does not use complete, accurate, and consistent data that fully demonstrate results. Source data for the metric have not passed DOD audits for at least 3 years, and the metric does not assess the readiness of reservists who comprise a substantial portion of combat casualty care capability. Also, according to congressional testimony and related research an estimated 25 percent of combat deaths were potentially preventable but were not related to provider readiness. Thus, the metric may not lead to expected improvements in patient outcomes in operational environments. Until DOD identifies and mitigates limitations in the readiness metric data, leaders may not have the best information to support decision-making.

DOD has not made decisions about the specialties to which its metric should apply or budgeted for full implementation of the metric. DOD plans to develop a metric for 72 provider specialties. However, GAO found that 12 specialties do not deploy. According to OSD officials, few of the 72 specialties (i.e., those that practice combat casualty care) rely on highly complex skills that may rapidly degrade without regular practice and would benefit most from a metric. DOD officials stated that the metric's implementation costs may be substantial and the return on investment may differ by specialty. Moreover, DOD has not fully budgeted for implementing the metric by, for example, funding additional training for providers to meet readiness thresholds. Until DOD determines the critical wartime medical specialties to apply its clinical readiness metric and estimates the costs and benefits of applying the metric to each, it will not know if its implementation is being targeted to the areas of greatest return on investment.

Why GAO Did This Study

In recent years, the Senate Armed Services Committee and DOD have raised concerns that the military health system has prioritized peacetime care to the detriment of combat casualty care capability and wartime medical skills.

Senate Report 115-125 included a provision for GAO to review DOD's efforts to address requirements from the National Defense Authorization Act for Fiscal Year 2017 regarding the required numbers of medical and dental personnel and wartime readiness. This report examines the extent to which DOD has (1) determined and reported to Congress on its operational medical and dental personnel requirements, and (2) initiatives to maintain and a methodology to assess the critical wartime readiness of medical providers. GAO reviewed DOD reports and personnel requirements data for fiscal year 2017 and future years, and interviewed senior DOD leaders as well as officials at six military treatment facilities to represent each military department and provide a mix of patient volumes.