Defense Health Care: Plans Needed to Ensure Implementation of Required Elements for TRICARE's Managed Care Support Contracts

In fiscal year 2018, DOD provided health care services to more than 9 million eligible beneficiaries through TRICARE, its regionally structured health care program. In each of its two regions (East and West), DOD uses contractors to manage health care delivery through civilian providers. The NDAA 2017 required a number of changes to the TRICARE program through its contracts. Specifically, it required DOD to implement a strategy with 13 specific elements—related to provider networks, telehealth services, and referrals, among other areas—for its contracts.

The NDAA 2017 and the accompanying Senate Report 114-255 included provisions for GAO to examine DOD's managed care support contract acquisition process and requirements. This report (1) describes changes DOD made to its TRICARE contracts and acquisition process between its T-3 and T-2017 contracts and (2) examines the extent to which DOD implemented the 13 elements as required by the NDAA 2017, among other things. GAO reviewed and analyzed relevant federal statutes, T-3 and T-2017 planning and contracting documents, and interviewed DOD officials and TRICARE contractors.

The Department of Defense (DOD) made selective changes to its TRICARE managed care support contracts and acquisition process from the third generation of contracts (T-3) to the fourth generation (T-2017) of contracts. According to DOD officials, the contracts are generally the same, and changes were made to clarify or streamline TRICARE requirements and administrative processes. Officials told GAO they prioritized the continuation of beneficiary services, rather than implement significant contract changes that could potentially be disruptive. Some of the T-2017 changes include a reduction from three to two contract regions and a different method for paying the contractors.

GAO found that DOD has partially implemented six of the 13 elements required by the National Defense Authorization Act for Fiscal Year 2017 (NDAA 2017), in its T-2017 contracts. DOD leadership explained that they decided to implement each of the 13 elements separately rather than by developing a single strategy that addressed all of the elements. DOD officials explained that some of the 13 elements will be implemented through modifications to the T-2017 contracts, while others will be addressed in the fifth generation of managed care support contracts (T-5), which are expected to be awarded in 2021. While DOD has taken steps to begin implementing some of the required elements, GAO found that DOD lacks plans with specific time frames and actions needed to fully implement all of the elements. As a result, it is unclear exactly how and when all 13 elements will be implemented.

GAO recommends that DOD develop and implement plans with time frames and specific actions needed for all 13 required elements in the TRICARE contracts. DOD concurred with GAO's recommendation and noted its plans to address each of the required elements in the T-5 contracts.

In fiscal year 2018, the Department of Defense (DOD) offered health care  services to more than 9 million eligible beneficiaries worldwide through  TRICARE, its regionally structured health care program. Beneficiaries  may obtain health care services through DOD’s direct care system of  military hospitals and clinics—referred to as military treatment facilities— or from its purchased care system of civilian providers. In each of its  TRICARE regions, DOD contracts with private sector companies— referred to as managed care support contractors—to develop and  maintain networks of civilian providers and perform other customer  service functions, such as processing claims, enrolling beneficiaries, and  assisting beneficiaries with finding providers. In fiscal year 2018,  purchased care accounted for about 54 percent of the total costs for  health care services delivered to TRICARE beneficiaries.

Within DOD, the Defense Health Agency (DHA) administers the  TRICARE program, which includes awarding and overseeing the  managed care support contracts (contracts) and setting policy for both the  direct and purchased care systems, among other responsibilities. In July  2016, DHA awarded its fourth generation of TRICARE contracts, referred  to as the T-2017 contracts, to succeed its third generation of contracts,  referred to as the T-3 contracts.

The National Defense Authorization Act for Fiscal Year 2017 (NDAA  2017), enacted in December 2016, required a number of changes to the  TRICARE program through its contracts. Specifically, it required DOD to  develop and implement value-based incentive programs that typically  reward providers with additional payments for improved performance  based on certain quality and efficiency metrics. In addition, the act  directed DOD to develop and implement a strategy—by January 1,  2018—for its TRICARE contracts that includes 13 specific elements  related to provider networks, telehealth services, and referrals, among  other areas. These elements are intended to improve access to care,  health outcomes, quality of care, beneficiaries’ experience, as well as  lower costs to the department. The NDAA 2017 required DOD to modify  its TRICARE contracts to ensure consistency with the required strategy  providing for the 13 specific elements.

The NDAA 2017 and the accompanying Senate Report 114-255 also  included provisions for us to examine issues related to DHA’s managed  care support contract acquisition process and requirements. In this  report, we  1.  describe changes DHA made to its TRICARE contracts and  acquisition process between its T-3 and T-2017 contracts,  2.  examine the extent to which DHA implemented value-based incentive  programs as required by the NDAA 2017, and  3.  examine the extent to which DHA implemented the 13 elements as  required by the NDAA 2017.

To describe changes DHA made to its TRICARE contracts and  acquisition process between its T-3 and T-2017 contracts, we reviewed  the T-3 and T-2017 contract documents as well as acquisition planning  documents, such as the T-3 and T-2017 Acquisition Strategy and the  Acquisition Plan. We interviewed TRICARE acquisition officials and  representatives from the two T-2017 managed care support contractors— Humana Government Business and Health Net Federal Services—about  the process to award the T-2017 contracts and any changes between the  T-3 and T-2017 contracts. We compared relevant contract changes  provided by DHA that may be consistent with certain provisions in section  705 of the NDAA 2017. These provisions are related to improving access  to care, health outcomes, health care quality, experience of care for  covered beneficiaries, and lowering health care costs. In addition, we  identified statutory acquisition themes pursued by Congress over the last  5 years to improve the way federal agencies acquire goods and services.  Specifically, we reviewed the NDAAs for fiscal years 2015 through 2019  and identified common themes aimed at improving DOD and federal  contracting and acquisition practices. We determined that three of these  acquisition themes were relevant to the TRICARE program, including (1)  following commercial best practices, (2) promoting competition, and (3)  focusing on value. We then identified T-2017 contract changes that  incorporated or were consistent with these themes.

To examine the extent to which DHA implemented value-based incentive  programs as required by the NDAA 2017, we reviewed the provisions of  section 705(a) of the NDAA 2017, DHA’s January 2018 report to  Congress on its efforts to implement a value-based pilot program, and  specific sections of the 2015 edition of the TRICARE Operations Manual  that describe DHA’s implementation of value-based pilots and  demonstrations. We also reviewed DHA’s decision papers that  summarized the value-based pilots and demonstrations as well as DHA’s  modifications to the T-2017 contracts to implement them. We conducted  interviews with DHA officials and representatives from the two managed  care support contractors to discuss the status of the department’s value- based program efforts.

To examine the extent to which DHA implemented the 13 elements as  required by the NDAA 2017, we reviewed the provisions in section 705(c)  of the NDAA 2017 as well as specific sections of the 2015 edition of the  TRICARE Operations Manual and the TRICARE Policy Manual that have  information related to the 13 required elements. We also reviewed any  modifications DHA made to the T-2017 contracts associated with the  required elements. We interviewed officials from DHA, including DHA  leadership, the Chief of the TRICARE Health Plan, and other DHA staff  involved in the implementation of the required elements, as well as  representatives from the two managed care support contractors, to obtain  information on the status of the department’s efforts and any additional  planned activities. We assessed this information against the 13 required  elements to determine the extent to which DHA had implemented them.  Based on our review, we established three categories to describe the  extent of implementation: (1) not implemented, (2) partially implemented,  and (3) fully implemented. We also evaluated DHA’s efforts against  sound practices for planning, as reported in our prior work.

We conducted this performance audit from November 2018 to February  2020 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.

Fourth Generation TRICARE Contracts (T- 2017)

For the T-2017 contracts, DHA consolidated its TRICARE regions from  three regions (North, South, and West) to two regions (East and West).  Humana Government Business is the managed care support contractor  for the East Region, and Health Net Federal Services is the managed  care support contractor for the West Region. Health care delivery under  the T-2017 contracts began on January 1, 2018.

DHA expects the costs of the two contracts to total approximately $58  billion over a 5-year performance period, which is scheduled to end on  December 31, 2022. The primary responsibilities of the managed care  support contractors include the following: developing civilian provider networks, which include hospitals and processing referrals and authorizations for beneficiaries to receive processing health care claims; providing comprehensive, readily accessible customer services for  beneficiaries and providers; and establishing and maintaining a medical management program that  includes requirements in the TRICARE Operations Manual.

In addition, DHA officials told us that they have begun their planning  activities for the fifth generation of TRICARE contracts, referred to as the  T-5 contracts. If DHA exercises all option years for the T-2017 contracts,  health care delivery under the T-5 contracts is expected to begin in  2023.

Overview of the Acquisition Process for the T-2017 Contracts

DHA’s acquisition process for the T-2017 contracts consisted of four  steps: (1) planning the acquisition, (2) issuing the Request for Proposals  (RFP) and soliciting responses, (3) awarding the contracts, and (4) post  award activities (see figure 1).  1.  Acquisition planning. DHA defined the contract requirements—the  work to be performed by the contractor—and developed an  acquisition plan to meet those requirements. The T-2017 program  manager and contracting officer developed key acquisition  documents—including the T-2017 Acquisition Strategy and the  Acquisition Plan—and conducted market research. The T-2017  Acquisition Strategy provides a high-level description of the  milestones in the acquisition process and how those milestones will  be achieved. The T-2017 Acquisition Plan outlines the specific actions  necessary to execute the approach outlined in the approved  acquisition strategy.  2.  Request for proposals. DHA issued an RFP that documented the  requirements for T-2017—including the contract type, significant  contract dates, pricing arrangements, and the criteria to be used to  assess offerors’ proposals.  3.  Award. DHA established a source selection team to evaluate the  proposals received in response to the RFP. The source selection  authority selects the winning proposals using a best value tradeoff  process after considering reports written by other members of the  source selection team.  4.  Post-Award Activities. DHA provides a 12-month transition period  between its outgoing and incoming contractors to ensure that its  incoming contractors are prepared for their new responsibilities. The  transition period for the T-2017 contracts began on January 1, 2017,  and ended on December 31, 2017. The incoming contractors  assumed full responsibility for health care delivery on January 1,  2018.

The NDAA 2017 required a number of changes to the TRICARE program  through its contracts. Specifically, section 705(a) of the NDAA 2017  required DOD to develop and implement value-based incentive programs  in its contracts to help improve the quality of health care services  provided to eligible TRICARE beneficiaries by rewarding civilian providers  with additional payments for improved performance based on certain  metrics. In addition, section 705(c) of the NDAA 2017 directed the  department to develop and implement a strategy—by January 1, 2018— for its TRICARE contracts that includes 13 specific elements, such as  telehealth services and beneficiary referrals, among others (see table  1). The act required DOD to modify its TRICARE contracts to ensure  consistency with the required strategy providing for the 13 elements.

DHA Made Selective Changes between the T-3 and T-2017 Contracts; Some Changes Are Consistent with Provisions and Themes in Prior NDAA Legislation

DHA made selective changes between the T-3 and T-2017 contracts and  acquisition strategy. According to DHA officials, the contracts are  generally the same, and changes were made to clarify or streamline  TRICARE requirements and administrative processes. The T-2017  Acquisition Strategy states that the T-2017 performance work statement,  which identifies the TRICARE requirements to be implemented by the  contractors, is essentially unchanged from the T-3 contracts. DHA  officials explained that their leadership prioritized the continuation of  beneficiary services during the T-2017 planning process over making  significant changes to contract requirements that could potentially be  disruptive. We found that some of the changes that were made to the T- 2017 contracts are consistent with specific provisions and themes we  identified in prior NDAA legislation.

Some Changes to the T- 2017 Contracts Are Consistent with Specific NDAA 2017 Provisions

Although the NDAA 2017 was enacted after the T-2017 contracts had  been awarded, some of the contract changes for T-2017 may be  consistent with specific provisions outlined in section 705(c)(1), such as  provisions related to improving access to care, health outcomes, health  care quality, beneficiaries’ experience, as well as lowering health care  costs. However, DHA officials stated that because health care delivery  under the T-2017 contracts began in 2018, it is too early to measure any  benefits from these changes. These contract changes include (1) the  consolidation of contract regions, (2) the combining of administrative  costs, and (3) the introduction of new contract incentives.  1.  Consolidation of contract regions. While DHA awarded the T-3  contracts for three regions (West, South, and North), it consolidated  two of the regions (North and South) for the T-2017 contracts (see  figure 2).

By eliminating the additional regional contract, DHA anticipates a savings  of approximately $25 million a year in overhead and management costs.  In addition, beneficiaries are less likely to have a disruption in care when  moving. For example, beneficiaries who moved between the former North  and South regions would now stay enrolled with the same contractor in  the larger East region.  2.  Combined administrative costs. For T-2017, DHA combined all  administrative costs in one contract line item in order to lower total  cost of care. For example, under the T-3 contracts, DHA reimbursed  the contractors for processing individual claims with a higher rate for  paper claims and a lower rate for electronic claims. Without a  difference in costs for T-2017, contractors are incentivized to lower  their costs and prioritize electronic claims, which DHA officials say are  more efficient.  3.  Contract incentives. DHA incorporated incentives into the T-2017  contracts to encourage contractors to negotiate reimbursement rate  discounts with network providers in order to reduce health care costs.  The T-2017 contracts state that the contractor must meet a required  discount rate on care provided by network providers. If this discount  rate is not met, DOD will offset the discount deficit amount from the  next payment due to the contractor. DHA expects that negative  incentive will reduce health care costs and result in government  savings.

Several Contract Changes Are Consistent with Acquisition Themes in Prior NDAA Legislation

We also found examples of changes to the contract or acquisition process  for T-2017 that are consistent with selected acquisition themes we  identified in prior NDAA legislation. These acquisition themes are 1)  leveraging commercial best practices, 2) promoting competition, and 3)  focusing on value. We previously reported that the identified acquisition  themes can reduce costs and increase value for the government.  1.  Leveraging commercial best practices: T-2017 required  contractors to increase utilization of commercial best practices,  including the use of automation technology to process referrals and  authorizations, episodes of care, and procedure diagnosis coding. As  we have previously reported, federal agencies can leverage  commercial best practices to lower costs and maximize the value of  the services they buy. According to DHA officials, adapting  automation technology already in use in the health care industry  should improve the quality of services, beneficiary satisfaction, and  result in cost savings to the government. In addition, officials from one  of the current TRICARE contractors stated that the T-2017 RFP was  structured to incentivize contractors to innovate and bring best  practices from their industry experience in both the commercial sector  and other government programs, such as Medicare. For example, the  T-2017 contract included a new requirement for contractors to use  industry best practices when collecting health care data, in order to  identify and reduce gaps in care and enhance quality of care for  beneficiaries.  2.  Promoting competition: We found that DHA made an effort to  promote competition for the T-2017 RFP. Competitive contracts can  result in cost savings for the federal government and promote  accountability for results. In the acquisition planning phase, DHA  identified an increased number of interested contractors through  market research, from eight for T-3 to 22 for T-2017. In addition, DHA  officials stated that they took steps during the acquisition planning  process to ensure that the incumbent contractors did not have a  significant advantage over prospective contractors. For example, the  T-2017 contracting officer was assigned early in the planning process  and did not participate in management of the T-3 contracts or in  interactions with the incumbent contractors. DHA officials stated that  they expected greater contractor interest in the East region because  the larger beneficiary population of that region would result in a more  valuable contract. However, DHA received a total of seven proposals  each for T-3 and T-2017, including one new company that participated  in T-2017 but had not previously submitted a proposal for T-3.  3.  Focusing on value: We found that DHA’s approach for T-2017  emphasizes value and quality, not just lower costs. Specifically, DHA  focused on the value of improving health care by considering the total  cost of care over time, rather than the cost of individual health care.  This is reflected in the T-2017 Acquisition Strategy, which prioritizes  quality and delivery of health care above lowest cost. For example,  the T-2017 contracts required additional preventive screenings and  diseases covered under a chronic care program to achieve improved  quality of care despite the cost of screenings. We have previously  reported that these preventive health services are determined to be  cost-effective when they improve the benefit (e.g., health outcomes) in  a less costly way than a given alternative care option. Some  preventive services may also result in cost savings, where the cost of  implementing the service is less than the expected future costs to  treat a disease or condition.

DHA Has Implemented Two Value-Based Incentive Pilots; Other Pilots Are Planned

As of October 2019, DHA had implemented two of the three value-based  pilots described in its January 2018 report to Congress, which outlines the  department’s plans for addressing the NDAA 2017’s requirement for  developing value-based incentive programs. Specifically, in this report,  DHA described its intent to implement three value-based pilots in  response to section 705(a) of the NDAA 2017—(1) the Performance- Based Maternity Payments Pilot, (2) the Medication Adherence Pilot, and  (3) the High-Value Primary Care Provider Pilot—through modifications to  its TRICARE contracts over the next 6 to 18 months.  1.  Performance-Based Maternity Payments Pilot. DHA modified its T- 2017 contracts to begin implementing the Performance-Based  Maternity Payments Pilot in April 2018. This pilot was designed to  provide both non-financial and financial incentives to hospitals that  achieve and maintain excellence in maternity care quality. The first  phase of this pilot focused on non-financial incentives by promoting  greater transparency about the quality of maternity care delivered by  hospitals in the TRICARE network. Specifically, DHA implemented a  “steerage model” that identifies higher-performing hospitals in the  managed care support contractors’ provider directories using specific  visual prompts in order to encourage beneficiaries to seek care from  those institutions. The second phase of the pilot began in October  2018 and incorporated performance-based payments, or financial  incentives, for network hospitals that achieve a certain level of  performance on specified maternity care quality measures. The  anticipated end date for the pilot is March 2021.  2.  Medication Adherence Pilot. DHA modified its TRICARE pharmacy  contracts to begin implementing the Medication Adherence Pilot in  February 2018. This pilot is designed to incentivize beneficiaries’  adherence to medication regimens by reducing or eliminating  copayments for two medications (one for diabetes and another for  cardiovascular-related illnesses).  3.  High-Value Primary Care Provider Pilot. As of October 2019, DHA  officials told us they were still assessing the feasibility of implementing  the High-Value Primary Care Provider Pilot, which would provide  financial incentives (such as additional payments or reduced network  discounts) to primary care providers who exceed certain quality  thresholds, as well as financial incentives (such as reduced co-shares  and copayments) for beneficiaries who use these providers.

DHA officials said other value-based efforts are being planned to address  section 705(a) of the NDAA 2017, such as value-based pilots and  demonstrations that aim to incentivize providers to provide quality care— including hospital, home health, and episode-based bundled payments  pilots, among others. DHA has reported that these projects will offer DHA  the opportunity to test value-based payment models and incorporate  innovative ideas and solutions into its TRICARE contracts.

DHA Has Partially Implemented Six of 13 Required Elements, but It Is Unclear When Implementation of All Elements Will Be Complete

As of January 2020, we found that DOD had partially implemented six of  the 13 elements required by sections 705(c)(5) and (c)(6) in the NDAA  2017, in its T-2017 contracts. DHA leadership explained that they had  decided that the department would separately address each of the 13  elements through modifications to the TRICARE contracts rather than  developing a single strategy that would address all of the elements.  According to DHA officials, some of the 13 elements would be  implemented through modifications to the T-2017 contracts while other  elements would be addressed in the T-5 contracts as certain elements  would require more time to develop.

Section 705(c)(5): This section includes nine elements that focus on  various aspects of health care delivery. We found that DHA had  partially implemented six of the nine elements—including provider  networks, medical management, telehealth services, beneficiary  enrollment, value-based methodologies, and prevention and wellness  incentives (see table 2). Although DHA officials generally described  their approach for addressing the three other elements, they were not  able to provide documentation, such as implementation plans, with  specific time frames or actions needed to fully implement each of  them. Specifically, when asked about time frames for complete  implementation, DHA officials told us that many of the elements  should be addressed through the T-5 contracts. DHA officials also told  us the department’s approach to addressing these elements—such as  provider networks—will be informed by ongoing and future value- based pilots and demonstrations; however, data from these pilots and  demonstrations are not expected to be available until they have  concluded.

Section 705(c)(6): This section included four required elements that  focus on the delivery of health care in rural, remote, and isolated  areas. DHA has not implemented any of these requirements. DHA  officials told us they are considering requirements for T-5 that will  address the four elements, but did not provide documentation with  specific time frames and actions needed to fully implement each of  them (see table 3).

Without plans that include specific time frames and actions needed, it is  unclear exactly how and when DHA will fully implement all 13 elements  into its TRICARE contracts. As we have previously reported, sound  planning calls for results-oriented organizations to develop plans that (1)  provide tools to ensure accountability, such as time frames, and (2)  identify specific activities to obtain desired results, among other things.  Developing and implementing plans with time frames and actions needed  can help to ensure that DHA fully implements all 13 required elements,  which is particularly important since it is in the process of developing its  T-5 contracts.

The NDAA 2017 required DHA to make numerous changes to its  TRICARE program—some of which impact its T-2017 managed care  support contracts. In particular, the act required DHA to modify these  contracts to ensure consistency with 13 specific elements related to  improving health care delivery, such as with provider network flexibility,  increased use of telehealth services, and prevention and wellness  incentives, among others. While DHA has taken steps to begin  implementing some of these elements in its current T-2017 contracts, it  has not developed implementation plans with time frames and specific  actions needed to guide its efforts, which could help ensure that DHA  successfully implements all of the required elements. Until these  elements are fully implemented, the department may not achieve the  TRICARE program improvements Congress intended related to access to  care, health outcomes, quality of care, beneficiaries’ experience, and cost  efficiency.

We are making the following recommendation to DHA:  The Director of DHA should develop and implement plans with  timeframes and specific actions needed for all 13 required elements to be  reflected in the TRICARE contracts. (Recommendation 1)

We provided a draft of this report to DOD for comment. In its written  comments, reproduced in appendix I, DOD generally agreed with our  findings and concurred with our recommendation. The department  reiterated its plans to address each of the elements required by sections  705(c)(5) and (c)(6) in the NDAA 2017 as part of its T-5 contracts. DOD  also provided technical comments, which we incorporated as appropriate.

In addition, DOD provided updated information on the status of its efforts  to address certain elements required by section 705(c)(5). As a result of  this information, we updated the status of the following two elements from  “not implemented” to “partially implemented” in our overall assessment for  the following reasons:  1)  Provider Networks: The department provided evidence that the  Accountable Care Organization demonstration was implemented  on January 1, 2020, and that beneficiaries were enrolled in the  program.  2)  Medical Management: The department provided evidence that it  awarded a contract for the TRICARE Select Patient Navigator  Pilot on December 27, 2019, and that the contractor began work  on January 1, 2020.

The department also provided updates on the status of two additional  elements—Financial Incentives and Medical and Lifestyle Incentives.  However, while we updated the department’s plans for these elements in  the report, we determined that their status should remain “not  implemented” in our overall assessment for the following reasons:  1)  Financial Incentives: The department provided evidence that it  plans to provide financial incentives to Kaiser Permanente  providers on an annual basis under the Accountable Care  Organization demonstration. These incentives are expected to  begin in 2021.   2)  Medical and Lifestyle Incentives: According to department  officials, these incentives for beneficiaries may be provided by  Kaiser Permanente on an annual basis under the Accountable  Care Organization demonstration, at no cost to the government.  These officials told us they were unsure whether and how such  incentives may be more broadly applied to the TRICARE program.

We are sending copies of this report to the Department of Defense,  appropriate congressional committees, and other interested parties. In  addition, the report will be available at no charge on the GAO website at  http://www.gao.gov.

If you or your staff have any questions about this report, please contact  Sharon Silas, Director, Health Care at (202) 512-7114 or silass@gao.gov  or William T. Woods, Director, Contracting and National Security  Acquisitions at (202) 512-4841 or woodsw@gao.gov. Contact points for  our Office of Congressional Relations and Office of Public Affairs can be  found on the last page of this report. Other major contributors to this  report are listed in appendix II.

Appendix I: Comments from the Department of Defense

Appendix II: GAO Contacts and Staff Acknowledgments

In addition to the contact named above, Bonnie Anderson, Assistant  Director; La Sherri Bush, Analyst-in-Charge; LaKendra Beard, Jacquelyn  Hamilton, Jessica Karnis, Miranda Riemer, and Lauren Wright made  contributions to this report. Also contributing were Sam Amrhein and Vikki  Porter.

The Defense Department’s TRICARE program pays for health care services for more than 9 million beneficiaries.

Congress in 2016 required DOD, among other things, to come up with a strategy to improve TRICARE that addressed 13 specific elements related to health care delivery—including provider networks, telehealth services, and referrals, among others.

DOD has partially implemented 6 of these elements. We recommended that DOD spell out time frames and specific actions to be taken to fully implement all 13 elements.