Defense Health Care: Additional Information and Monitoring Needed to Better Position DOD for Restructuring Medical Treatment Facilities

DOD's MTFs are critical to the medical readiness of servicemembers and providing readiness training for about 107,000 active-duty medical providers. About 9.6 million beneficiaries are eligible for DOD health care through MTFs and civilian network providers. To further support readiness, the National Defense Authorization Act (NDAA) for Fiscal Year 2017 required DOD to plan to restructure MTFs. DOD's February 2020 Plan included decreasing capabilities at 43 MTFs and closing five.

The NDAA included a provision for GAO to review the Plan. This report addresses the extent to which 1) the Plan's methodology prioritized statutory elements and considered complete information, and 2) DOD is positioned to execute MTF restructuring transitions. GAO reviewed DOD's Plan, MTF workload and cost data, and interviewed DOD leaders and officials at 11 MTFs selected on the basis of military department, restructuring action, and location.

The Department of Defense's (DOD) methodology to determine Medical Treatment Facilities' (MTF) restructuring actions in its implementation plan (the Plan) prioritized statutory elements. These included military readiness, adequacy of nearby civilian health care, and cost-effectiveness. However, DOD based part of its methodology on incomplete and inaccurate information.

Civilian health care assessments did not consistently account for provider quality. DOD generally assumed that identified providers were of sufficient quality. GAO found that DOD considered the quality of nearby civilian providers for one of 11 selected MTFs. In this instance, information from the MTF about the variable quality of nearby civilian health care led to DOD's determination that such care was not yet adequate to support MTF restructuring. Officials GAO interviewed from other MTFs discussed concerns about quality of care from nearby civilian providers.

Civilian health care assessments did not account for access to an accurate and adequate number of providers near MTFs. DOD may have included in its assessments providers who do not meet DOD's access-to-care standards for certain beneficiaries. For 11 selected MTFs, GAO found that about 56 percent of civilian primary care providers and 42 percent of civilian specialty providers that DOD identified as being nearby exceeded DOD's drive-time standards. Including such providers in its assessments means that DOD could have overestimated the adequacy of civilian health care providers in proximity to some MTFs.

Cost-effectiveness assessments were based on a single set of assumptions. DOD concluded that civilian health care was more cost-effective than care in its MTFs without considering other assumptions that could affect its conclusions. For example, DOD applied assumptions about the cost of military personnel salaries, MTF workloads, and reimbursement rates for TRICARE that likely underestimated the cost-effectiveness of MTFs.

GAO also found that DOD conducted limited assessments of MTFs' support to the readiness of military primary care and nonphysician medical providers—an issue DOD officials stated they will address during MTF transitions. Until DOD resolves methodology gaps by using more complete and accurate information about civilian health care quality, access, and cost-effectiveness, DOD leaders may not fully understand risks to their objectives in restructuring future MTFs.

DOD's Plan identified actions needed to facilitate MTF restructuring, but the department is not well positioned to execute the transitions. DOD's Plan poses challenges for the military departments and the Defense Health Agency (DHA) related to MTF providers' readiness. Yet, DOD plans to move forward with restructuring without a process to monitor progress and challenges. By establishing roles and responsibilities for executing and monitoring MTF restructuring transitions, DOD can be better positioned to navigate organizational boundaries between the DHA that manages the MTFs and the military departments that provide staff. Additionally, by defining measurable objectives and progress thresholds, DOD can better ensure it is meeting objectives and facilitating timely adjustments to MTF restructuring transitions, as needed.

GAO is making six recommendations, including that future MTF assessments use more complete and accurate information about civilian health care quality, access, and cost-effectiveness; and that DOD establish roles, responsibilities, and progress thresholds for MTF transitions. DOD partially concurred with four recommendations and concurred with two. As discussed in the report, GAO continues to believe that all six recommendations are warranted.

The Department of Defense’s (DOD) Military Health System (MHS) exists  to ensure that servicemembers, including medical providers, are ready to  deploy and accomplish missions. To that end, DOD’s hospitals, medical  centers, and clinics—referred to collectively as military Medical Treatment  Facilities (MTF)—are critical to the MHS. In 2019, DOD maintained 475  MTFs worldwide to deliver health care to more than 1.3 million  servicemembers to ensure their medical readiness, and to provide  essential on-the-job training for about 107,000 active-duty medical  providers in support of their operational readiness. DOD’s hospitals and  medical centers are also designated to receive wartime casualties, and  can provide certain types of assistance to civil authorities during a U.S.  national emergency or domestic disaster.

About 9.6 million beneficiaries are eligible for DOD health care services,  including active-duty and retired servicemembers and their families,  dependent survivors, and certain reserve component members and their  families. DOD provides health care through its MTFs—referred to as  direct care—and through purchased care from private sector civilian  provider networks that DOD maintains to supplement its MTFs. DOD is  continuously challenged to balance the MTFs’ readiness mission with the  provision of safe, high-quality care to beneficiaries within a sustainable  budget. As the cost of the MHS increased over the past 2 decades as a  share of DOD’s base budget, DOD leaders have sought to improve  readiness while curtailing the growth of the Defense Health Program that  funds the MTFs and purchased care. DOD’s budget request for the  Defense Health Program has decreased from $33.7 billion in fiscal year  2019 to $33.1 billion in fiscal year 2021.

Section 703 of the NDAA for Fiscal Year 2017 required the Secretary of  Defense to submit to Congress an implementation plan to restructure or  realign MTFs to support the readiness of the armed forces and the  readiness of medical forces. DOD defines actions to “restructure or  realign” as decreasing capabilities at some MTFs, such as eliminating  inpatient functions from hospitals that will transition to clinics, and, to a  smaller extent, increasing capabilities at other MTFs, such as expanding  the available services at hospitals that will become medical centers. In  this report, we refer to restructure or realignment collectively as  “restructure.” In February 2020, DOD submitted the section 703(d)  implementation plan to Congress, which included actions to restructure  50 MTFs by decreasing capabilities at 43 them, closing another five  facilities, and increasing capabilities at two sites.

Section 703(d) of the NDAA for Fiscal Year 2017 set forth specific  elements that the implementation plan should include, such as, for each  MTF, whether it will be restructured, whether its functions will be  expanded or consolidated, and the related costs. Hereafter, we refer to  the implementation plan as “the Plan.” Section 703(d) also included a provision for us to review the Plan. This report addresses the extent to  which (1) DOD’s methodology for determining MTF restructuring actions  in the Plan prioritized cross-cutting elements from 10 U.S.C. § 1073d and  considered complete information, and (2) DOD has positioned itself to  execute transition planning for restructuring its MTFs. We also compared  the Plan with the applicable elements and found that it generally  addressed a number of the elements, and stated that other elements will  be addressed in forthcoming detailed implementation plans.

For both objectives, we used a case study approach to review DOD’s  methodology for determining restructuring actions and steps that may be  needed for subsequent transition planning. From DOD’s initial list of 73  MTFs included in its scope, we selected 11 to represent a variety of  characteristics, including a mix of hospitals and clinics from each military  department, different recommendations for how they should be  restructured, different conclusions about network adequacy, and urban  and rural areas located in proximity to one another in terms of driving  distance. While the case study findings are not generalizable, they  provide illustrative examples for each objective. A list of the 11 MTFs we  selected is included in appendix I.

For objective one, we reviewed DOD’s draft and final Plan and related  documentation of the methodologies used to assess all 77 MTFs within its  final scope. We compared this information with cross-cutting elements  from 10 U.S.C. § 1073d. These elements include the (1) support an MTF  provides to servicemembers’ medical readiness and the readiness of  medical personnel, (2) adequacy of civilian health care in proximity to  each MTF, and (3) cost-effectiveness of direct care services at MTFs  versus purchased care in nearby civilian provider networks. In addition,  we discussed the methodological approaches, including assumptions,  data sources, and any limitations, with DOD officials and officials from the  11 selected MTFs.

Specifically, in reviewing DOD’s methodology for assessing MTFs’  support to readiness, we reviewed information used to estimate MTFs’  readiness value in terms of support to servicemembers’ medical  readiness and to medical force readiness. We also reviewed records of  interviews that DOD officials held with MTF, installation, and command  officials, noting the readiness-related effects and concerns that were  documented.

For DOD’s assessments of available civilian health care services in  proximity to each MTF, we reviewed reports on the results of DOD’s  assessments to identify their findings, recommendations, and  assumptions. For the civilian health care providers that DOD identified as  being in proximity to each of our selected MTFs, we verified the address  of each listed provider and calculated the distance between the provider  and the MTF, comparing the distance with DOD’s access-to-care  standards. We evaluated the extent to which the assessments  considered information about quality of health care services and access- to-care standards, comparing the information with DOD guidance for  patients’ access to quality and timely health care services, and with  federal internal control standards on the use of quality information to  inform decision-making.

Regarding DOD’s assessments of MTF cost-effectiveness, we reviewed  DOD’s workpapers and interviewed officials about the calculations and  source data they used. We compared this information with our  assessment methodology for economic analysis and with DOD guidance  for economic analysis. We also obtained the fiscal years 2017 and 2018  data DOD used to calculate the cost-effectiveness of MTF-provided direct  care relative to civilian-provided purchased care. Using these data, we performed a sensitivity analysis by recalculating the unit-level cost of care  under different assumptions, such as omitting military personnel salaries  given that DOD has characterized these as a fixed cost. We assessed  the reliability of each data source for DOD’s and our calculations of cost- effectiveness by administering questionnaires about the data to those  who have quality control responsibilities, interviewing responsible DOD  officials, reviewing the data for outliers and missing values, and reviewing  our prior reports about the data. We determined that DOD’s data on the  costs of MTF care and purchased care were sufficiently reliable for the  purpose of calculating the total costs of health care services. However,  DOD’s data on units of health care delivered in fiscal year 2018 were of  undetermined reliability for the purpose of calculating a unit-level health  care cost. We discuss these concerns later in the report.

For objective two, we reviewed DOD’s draft and final Plan, including  detailed appendices on the MTFs within the scope of the plan, noting any  aspects of transition planning described, and the agencies and  organizations that would be responsible for managing those transition  aspects. We also interviewed MTF officials at our selected case study  locations regarding steps they had taken or expected would be needed as  a result of a recommendation for restructuring their facility. We compared  these steps with practices identified in our prior work on results-oriented  government. These practices include establishment of (1) a process for  monitoring progress, (2) roles and responsibilities, (3) committed  leadership from all levels of an organization, and (4) a dedicated team  vested with necessary authority and resources to help set priorities, make  timely decisions, and move quickly to implement decisions. We provide  further details on our scope and methodology in appendix I. In addition,  appendix II identifies the names and locations of each MTF within the  scope of DOD’s Section 703(d) review and Plan, and from which we  selected our 11 case studies.

We conducted this performance audit from February 2019 to May 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.

Background Organizational Roles and Responsibilities for Managing the MHS

The MHS is a complex organization in which responsibility for health care  delivery is shared among the military departments—the Army, the Navy,  and the Air Force—and the Defense Health Agency (DHA), with oversight  from the Office of the Secretary of Defense and advice from the Joint  Staff. As such, several leaders have responsibility for DOD’s medical  workforces, their readiness, and the MTFs to which many of them are  assigned. Specifically:

The Under Secretary of Defense for Personnel and Readiness is the  principal staff assistant and advisor to the Secretary and Deputy  Secretary of Defense for health-related matters and, in that capacity,  develops policies, plans, and programs for health and medical  affairs.

The Secretaries of each military department are responsible for  organizing, training, and equipping military forces as directed by the  Secretary of Defense as well as responsibilities related to ensuring  the readiness of military personnel, and providing military personnel  and other authorized resources in support of the combatant  commanders and the DHA.

The Surgeon General of each respective military department serves  as the principal advisor to the Secretary of the military department  concerned on all health and medical matters of the military  department.

The Assistant Secretary of Defense for Health Affairs (ASD(HA))  serves as the principal advisor for all DOD health-related policies,  programs, and activities. He or she has the authority to develop  policies, conduct analyses, provide advice, and make  recommendations to the Secretary of Defense and others; issue  guidance; and provide oversight on matters pertaining to the MHS.  Further, the ASD(HA) prepares and submits a DOD unified medical  program budget which includes, among other things, the Defense  Health Program budget to provide resources for MTFs and the  TRICARE Health Program.

The Director of the DHA manages, among other things, the execution  of policies issued by the ASD(HA) and manages and executes the  Defense Health Program appropriation. The Director of the DHA is  also responsible for the TRICARE Health Program. In December  2016, Congress expanded the role of the DHA by directing the  transfer of responsibility for the administration of each MTF from the  military departments to the DHA. By no later than September 30,  2021, the Director of the DHA will be responsible for the  administration of each MTF. Specifically, the Director of the DHA will  be responsible for budgetary matters, information technology, health  care administration and management, administrative policy and  procedure, and military medical construction, among other things. As  of October 2019, the DHA had assumed administration and  management responsibilities for all MTFs within the United States.

MHS Workforces and the Role of MTFs in Supporting Military Readiness

In fiscal year 2019, DOD’s Defense Health Program-funded workforce  numbered over 174,000 personnel, comprising active-duty  servicemembers from each military department (the Army, the Navy, and  the Air Force), federal civilian employees of DOD, and private-sector  contractors. These personnel included health-care providers, such as  physicians (both primary and specialty care providers), nurses, and  enlisted specialists who assist with medical procedures, and  administrative and support personnel.

MTFs vary in size and capabilities from small clinics, to ambulatory  surgery centers, hospitals, and medical centers. Clinics generally provide  primary-care services, which may include pediatrics at some locations.  Other health-care services at clinics range from urgent care, women’s  health, occupational health, and behavioral health, to orthopedics and  other specialty services depending on location and population demand,  according to MHS officials. Some clinics treat only active-duty  servicemembers. Other clinics, along with hospitals and medical centers,  also serve other eligible beneficiaries, including military family members,  retirees, and some civilian employees of DOD. DOD’s hospitals provide  emergency medicine, inpatient care and other specialty care services  depending on population demand, according to MHS officials. For  example, they generally offer surgical capabilities and labor and delivery  services.

According to DOD Instruction 6000.19, the primary purpose of MTFs is to  support the readiness of the military services. In addition, the guidance  states that the size, type, and location of MTFs must further this  readiness objective. Further, each MTF must spend most of its resources  supporting wartime skills development and maintenance for military  medical personnel, or the medical evaluation and treatment of  servicemembers. To that end, MTFs serve as training and readiness  platforms for active-duty medical providers in two respects. First, many  MTFs host graduate medical and dental education programs for  physicians and dentists, and other training and education programs for  medical providers. Graduate medical education (GME) programs train  physician specialties through internships, residencies, and fellowships,  thereby helping maintain the necessary pipeline of physicians to staff the  MTFs and to deploy in support of military operations. The MTFs host  non-GME training and education programs for other medical personnel,  such as physician assistants, nurses, and enlisted technicians, which help  them attain and maintain their skills.

Second, day-to-day patient care at MTFs helps maintain the clinical skills  and readiness of medical providers. The military departments track  clinical readiness for providers using a series of checklists for deployable  medical specialties. In addition, since 2018, DOD has piloted a clinical  readiness metric for select physician specialties that provide combat  casualty care. To meet the metric, a physician must attain a minimum  threshold of points that indicate the complexity, diversity, and volume of  patient care they provided. Finally, the MTFs also maintain data on  physicians’ clinical workloads to measure their productivity against  benchmarks and thereby approximate their clinical readiness. These  clinical workload data are recorded as work Relative Value Units (wRVU),  a metric of the level of professional time, skill, training, and intensity to  provide a given clinical service.

Under TRICARE, DOD maintains a purchased-care system of civilian  providers to augment MTF capabilities. In each TRICARE region (East  and West), 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. The Director of the DHA awards and oversees the  managed-care support contracts.

TRICARE’s non-Medicare-eligible beneficiaries generally obtain coverage  through two health plan options—TRICARE Prime (a managed-care  option) and TRICARE Select (a self-managed, preferred provider  option). All active-duty servicemembers are required to enroll in the  Prime option, while other TRICARE beneficiaries may choose it. Prime  enrollees receive most of their care from MTFs and also may receive  purchased care from network civilian providers. Prime has the lowest out- of-pocket costs for beneficiaries, as care provided at MTFs does not have  a copayment. TRICARE Prime has five access standards that set  requirements for (1) travel time to provider sites, (2) appointment wait  time, (3) availability and accessibility of emergency services, (4)  composition of network specialists, and (5) office wait time.

TRICARE Select beneficiaries are able to obtain health care from network  and non-network providers. They can also receive care from MTFs, but  they have a lower priority for receiving care than TRICARE Prime  beneficiaries and are seen on a space-available basis.

MTF Statutory Requirements and MHS Governance to Implement Reforms

Section 703(a) of the NDAA for Fiscal Year 2017 added section 1073d to  title 10, United States Code, which set forth various requirements for  MTFs. To support the medical readiness of the armed forces and the  readiness of medical personnel, the Secretary of Defense is required to  maintain three types of MTFs—medical centers, hospitals, and  ambulatory care centers (or clinics). All of these MTFs are required to  provide specific health services required to maintain medical readiness.  Hospitals are to be located in areas where civilian health care facilities  are unable to support the health care needs of members of the armed  forces and covered beneficiaries. Both hospitals and clinics are to provide  limited specialty care that is cost-effective or is not available at civilian  health care facilities in the area.

In 2017, DOD appointed a Reform Leader for Health Care Management.  Among other responsibilities, the Reform Leader led a work group to  address Section 703 (hereafter, we refer to this as the 703 Work Group).  The 703 Work Group included representatives from the Office of the  ASD(HA), DHA, Joint Staff, the military services, and the TRICARE  Health Plan. Together, the 703 Work Group members led DOD’s efforts  to address section 703(c) of the NDAA for Fiscal Year 2017 by updating  its 2016 Report on Military Health System Modernization (“the  Modernization Study”) to address the future restructuring of MTFs  pursuant to 10 U.S.C. § 1073d; determine the scope of its review of MTFs in the United States (i.e.,  identify which MTFs to evaluate for the Plan, as opposed to those to  evaluate at a later date); develop MTF-specific recommendations for whether to restructure an  MTF and in what ways to do so by developing and applying a  methodology to assess each MTF in accordance with 10 U.S.C. §  1073d; and draft the final section 703(d) Plan to Congress delineating the  restructuring actions it determined.

In making determinations for selected MTFs, the 703 Work Group drafted  a “Use Case” for each MTF summarizing potential restructuring actions  and their analytical basis. The Work Group presented each MTF “Use  Case” for review to a team of senior DOD leaders, including the Under  Secretary of Defense for Personnel and Readiness, the ASD(HA), the  undersecretaries of the military departments, and military service leaders,  among others. When the senior leaders agreed on the restructuring  actions for the MTFs, the 703 Work Group presented those  determinations to the Secretary of Defense for approval.

In recent years, DOD leaders have taken steps to refocus the MTFs as  platforms for sustaining high-quality combat casualty care and the  operational readiness of active-duty medical providers while increasing  efficiency, in part by responding to congressional mandates. In 2016, for  example, DOD submitted the Modernization Study to Congress in  response to section 713 of the Carl Levin and Howard P. “Buck” McKeon  National Defense Authorization Act (NDAA) for Fiscal Year 2015. Its  main goals were to increase medical force readiness to support military  operations and achieve cost savings. The Modernization Study included  an MTF analysis of 24 hospitals to determine whether they should  maintain inpatient capabilities or birthing centers. It recommended  changes for 10 of the 24 hospitals, including closing inpatient services in  whole or part at eight of them. In September 2016, we reported that the  Modernization Study’s recommendations positioned DOD to improve the  effectiveness and efficiency of the MHS, but there were shortcomings in  its methodology. To strengthen any future assessments of MTF  changes, we recommended that DOD describe steps taken to assess the  reliability of supporting data. DOD concurred with the recommendation  and has taken some steps to implement it.

In response to other provisions in the NDAA for Fiscal Year 2017, DOD  has made reforms aimed at improving the MHS focus on readiness. Our  prior work has made recommendations to address gaps in those reforms.  For example, in February 2019 we reported that DOD had not determined  the required size and composition of its operational medical and dental  forces who support the wartime mission or submitted a complete report to  Congress, as required by section 721 of the NDAA. We recommended  that DOD establish joint planning assumptions and a method for  assessing efficiencies and risk, use them to determine its operational  medical and dental requirements, and report the requirements to  Congress. DOD concurred but had not implemented the  recommendations as of May 2020. We also reported in February 2019  that DOD had begun initiatives to maintain the wartime readiness of  medical providers in response to section 725 of the NDAA for Fiscal Year  2017. However, DOD’s methodology was limited with respect to a key  initiative—the use of a metric to assess medical providers’ clinical  readiness. We made three recommendations to improve DOD’s  application of the metric. DOD concurred but had not implemented them  as of May 2020. According to MHS leaders, efforts to identify the required  number of operational medical personnel and the level of readiness they  must maintain (pursuant to sections 721 and 725) were foundational  steps toward section 703 of the NDAA for Fiscal Year 2017. A list of  other related products is also included at the end of this report.

DOD’s Methodology for Determining MTF Restructuring Actions Prioritized Cross- Cutting Statutory Elements, but Included Some Incomplete and Inaccurate Information

The DOD 703 Work Group’s methodology for determining MTF  restructuring actions was thoroughly documented and prioritized cross- cutting statutory elements, including support for military readiness,  adequate nearby civilian health care, and cost-effectiveness. However,  the group based key parts of its methodology on some incomplete and  inaccurate information.

The 703 Work Group Evaluated MTFs’ Support for Military Readiness, Nearby Civilian Health Care, and Cost- Effectiveness, and Documented This Approach and Its Results

In reviewing the 703 Work Group’s methodology for determining MTF  restructuring actions, we found that the group prioritized cross-cutting  elements from 10 U.S.C. § 1073d to guide its approach. Its methodology  to evaluate each selected MTF consisted of data analyses and interviews  with officials from the MTF and its host installation. The 703 Work Group  based its MTF evaluation determinations on, by order of priority, the (1)  support each MTF provides to servicemembers’ medical readiness and  the readiness of military medical providers, (2) adequacy of civilian health  care facilities and providers to support the health care needs of  servicemembers and other beneficiaries through purchased care near  where each MTF is located, and (3) the cost-effectiveness of direct care  services at the MTF relative to purchased care in the area. In addition to  thoroughly documenting this methodology for evaluating the MTFs, the  703 Work Group documented the basis for the resulting conclusions.

Servicemembers’ and military medical providers’ readiness.  According to 703 Work Group leaders, as a first step in developing a  methodology for evaluating MTFs for restructuring actions, they decided  on a strategy they believed would prioritize MTF support to  servicemembers’ medical readiness and the readiness of military medical  personnel. To that end, the Work Group established minimum criteria to  determine an MTF’s level of support to readiness. In most cases, the  Work Group determined that MTFs should maintain certain minimum  capabilities for servicemembers’ individual medical readiness, including  primary care and, on a case-by-case basis, specialty services such as  behavioral health and physical therapy. In addition, through site visits  and interviews with MTF and installation personnel, the Work Group  determined that certain MTFs should maintain urgent and emergency  care services if they support a large training component on an installation.

The other element of the 703 Work Group’s strategy to prioritize  readiness was to evaluate the contribution of each MTF toward the  clinical readiness of military medical providers and recommend  restructuring actions on the basis of attaining minimum standards therein.  In particular, our review of methodology documents revealed the Work Group prioritized MTFs’ support to the readiness of combat casualty care  physicians. In doing so, the Work Group analyzed clinical workloads  (e.g., wRVUs) and readiness metrics to identify which MTFs supported  the physicians’ attainment of minimum thresholds. Finally, the Work  Group determined that MTFs that host a GME program for training a  combat casualty care or other physician specialty, or a graduate dental  education program, should preserve the inpatient services required to  continue the program.

Adequacy of nearby civilian health care. A secondary criterion the 703  Work Group applied in its methodology for evaluating MTFs for  restructuring was its determination of whether civilian health care facilities  and providers in proximity to a given MTF (i.e., TRICARE network  providers as well as non-network providers) were adequate to absorb an  increased demand for certain health care services from the MTF—that is,  whether DOD could use purchased care from civilian providers to replace  care divested from a restructured MTF. According to Work Group officials,  their strategy in applying this criterion was to reduce or eliminate health  care services from MTFs if those capabilities (1) were not needed for  readiness purposes and (2) could be adequately replaced with civilian  facilities and providers through purchased care.

In making this determination, the 703 Work Group conducted two  assessments for each evaluated MTF. These assessments applied  different criteria and assumptions to determine the adequacy of civilian  health care, as shown in table 1. In addition, the Work Group  supplemented the assessments by interviewing MTF and installation  personnel to gain their perspectives about the availability of civilian care  nearby.

Cost-effectiveness of direct-care services at MTFs. Last in order of  priority was the 703 Work Group’s determination of whether the MTF- delivered health care is cost-effective relative to nearby purchased care.  Specifically, the Work Group assessed whether the cost per unit of health  care delivered at each evaluated MTF was less than, equal to, or greater  than the unit cost of purchased care. According to Work Group officials,  these assessments supplemented the criteria on readiness and civilian  health care adequacy by lending a resource-informed perspective to the  overall methodology. A determination that an MTF’s unit costs exceeded  those of nearby purchased care would confirm to the Work Group that it  should consider replacing health care services from that MTF with  purchased care, provided that the group had first determined that the  corresponding capabilities (1) were not needed to support readiness, and  (2) could be adequately replaced with purchased care from civilian health  care providers nearby.

Table 2 below illustrates an example of the 703 Work Group’s calculation  of cost-effectiveness at one MTF it evaluated—the 2nd Medical Group  outpatient clinic at Barksdale Air Force Base in Louisiana. In this case,  the MTF’s unit cost in fiscal year 2017 was more than two times the cost  of purchased care. These results confirmed the Work Group’s  recommendation that some of the MTF’s capabilities should be replaced  with purchased care—specifically, the health care services that it  provided to non-active-duty servicemembers.

The 703 Work Group Based Parts of Its Methodology on Incomplete and Inaccurate Information

Notwithstanding the positive aspects of DOD’s methodology for  evaluating MTFs previously discussed, our review found that information  the 703 Work Group considered was sometimes limited in completeness,  accuracy, or both. Specifically, the Work Group (1) conducted limited  assessments of MTFs’ readiness support to military primary care and  nonphysician medical providers, and did not include, as part of its  methodology, (2) complete and accurate data about the quality of and  access to purchased care from civilian providers, or (3) alternative  assumptions that could affect the perceived cost-effectiveness of MTF- provided direct care.

Limited Assessments of MTFs’ Readiness Support for Primary Care and Nonphysician Medical Providers

The 703 Work Group conducted limited assessments of MTFs’ support  for the readiness of military primary care physicians and nonphysician  medical providers, including nurses, physician assistants, and enlisted  medical and surgical specialists, which constitute a substantial portion of  DOD’s medical forces. As discussed previously, the Work Group  prioritized assessments of MTFs’ support to combat casualty care  physicians’ readiness. For military primary care providers, the Work  Group determined whether a minimum amount of patient care workload  (i.e., RVUs) was available at each MTF to support productivity goals. This  was due in part to the fact that DOD has not developed a clinical  readiness metric for primary care and nonphysician providers as it has for  combat casualty care providers, according to Work Group officials.  Unlike a clinical readiness metric, a productivity goal does not account for  the types of workload needed for readiness. According to MTF medical  providers, they could meet their productivity goal as their MTF  restructures, but doing so would not ensure that they addressed diverse  and complex medical issues needed to maintain their clinical skills. MHS  senior leaders and MTF officials, including providers, expressed concern  that opportunities to treat diseases and nonbattle injuries will be limited in  MTFs that restructure to serve only active-duty servicemembers.

We also found that the 703 Work Group did not assess the support that  certain training and education programs provide to the readiness of  medical personnel at evaluated MTFs. The Work Group surveyed each  MTF within its scope to identify any graduate medical and dental  education and non-GME training and education programs the facility  hosts. The Work Group determined that nonprimary care GME and  graduate dental education programs are essential to maintain at MTFs,  but did not evaluate the readiness benefits of primary care GME and non- GME training to MTFs. We found that half of the MTFs identified for  restructuring as active-duty clinics or for closure host one or more non- GME training program for nurses, nurse practitioners, and enlisted  medical personnel, among others. Four MTFs that were deferred or  identified for reduction in capabilities or closure either host or support a  GME program for primary care physicians. MTF officials we interviewed  expressed concerns about the effects on military providers’ readiness  from reducing or displacing the programs. However, DOD’s Plan states  that any effects on GME and non-GME training programs will be  addressed later in a next phase of executing MTF restructuring  transitions, as discussed later in this report.

Incomplete and Inaccurate Information on Quality of and Access to Civilian Health Care Providers near MTFs

Although DOD assessed the availability of civilian health care providers  and facilities in proximity to MTFs, as described above, our review of  DOD’s assessments found that information gathered and applied in the  course of its methodology was sometimes incomplete and inaccurate.  Specifically, the information we reviewed did not consistently account for  the quality of available civilian health care providers in proximity to MTFs  and the extent to which those providers meet access-to-care standards,  as described in detail below. As a result, DOD’s assessments may have  included providers of lower quality health care and those who do not meet  DOD’s access-to-care standards. Including such providers in its  assessments means that DOD’s conclusions could be overestimated  regarding the adequacy of civilian health care providers in proximity to  some MTFs.

Quality of available care near MTFs. The 703 Work Group’s  assessments did not consistently account for the quality of available  providers located in proximity to each MTF. Although the TRICARE  Health Plan assessments documented and considered patient  satisfaction scores and quality ratings for hospitals from the Centers for  Medicare & Medicaid Services, its assessments of individual providers did  not contain information about quality of care. The independent  contractor’s assessments did not include any information about the  quality of available providers it identified. Instead, DOD generally  assumed that all identified providers were of sufficient quality.

Officials from the 703 Work Group stated that they sometimes discussed  the quality of available civilian health care during their site visits and  interviews with MTF officials. However, our review found that quality of  care was not consistently documented or considered for decision-making  purposes. For example, in our review of 11 selected MTFs, we found that  the Work Group documented and considered the quality of available  civilian health care in proximity to one of the 11 MTFs—Bayne-Jones  Army Community Hospital at Fort Polk, Louisiana. In this instance, the  Work Group’s information about the variable quality of civilian health care  near Fort Polk led to their determination that available care was not yet  adequate to restructure the MTF. Other MTF officials discussed with us  concerns they had about the quality of purchased care from some civilian  providers. Similarly, a recent study found that TRICARE-insured families  were less likely to report accessible or responsive care compared to  civilian peers, whether commercially or publicly insured or uninsured.

We have previously reported on concerns about DOD’s information about  the quality of purchased care. In September 2018, we reported that the  MHS does not monitor and report on quality measures for individual  civilian providers, although it does so for purchased care networks as a  whole. In contrast, the MHS maintains numerous measures for its MTFs  to track, assess, and report the quality of care and related patient  outcomes.

Access to an accurate and adequate number of current civilian  health care providers in the TRICARE networks. DOD’s assessments  of available civilian health care surrounding MTFs did not consistently  apply complete and accurate information about patients’ access to care in  terms of the number of available TRICARE providers in proximity to  MTFs. DOD’s assessments relied on the directories of network providers  (primary and specialty care) that are maintained by each of the regional  TRICARE contractors. In November 2019, we reported on problems with  the accuracy of these provider directories. Specifically, we reported that  as of June 2019, the TRICARE West region contractor’s directory of  network providers was 76 percent accurate and the East region’s was 64  percent accurate, according to DHA officials. However, we found that  the TRICARE Health Plan verified the accuracy of the directory entries of  network providers in proximity to only one of 77 MTFs—the Army’s  Farrelly Health Clinic at Fort Riley, Kansas. In this instance, the list of  available health care providers in proximity to Farrelly clinic was  overstated by 26 percent because of duplicate listings and practices that  had closed, among other factors.

Likewise, MTF officials we interviewed stated that the TRICARE network  directories in their area contained inaccurate information, such as  outdated provider listings, and overstated the number of providers who  were accepting new TRICARE patients.

Access to providers within standards for patients’ drive time. DOD’s  independent contractor assessments of available civilian health care  providers (both TRICARE network and non-network providers) used  some inaccurate information about those providers, especially their  locations. For 11 selected MTFs, we found that about 56 percent of  primary care providers and 42 percent of specialty care providers that an  independent contractor identified in its assessment exceeded DOD’s  drive-time standards for TRICARE Prime patients by varying degrees, as  shown in figure 1. A certain portion of the providers listed for each of the  11 selected MTFs were outside the drive-time standards, based on our  analysis. In addition, for each of the 11 selected MTFs, there was one or  more inaccuracies in the provider listing, such as providers that were no  longer in practice, duplicate providers, or those that were  mischaracterized as a medical provider. MTF officials we interviewed also  expressed concerns that the assessments did not account for traffic,  including bridges and tunnels that create traffic chokepoints. In other  words, they believed that even providers that appeared to be within drive- time standards based on mileage could actually exceed the standard  depending on their location and time of day. Appendix III illustrates the  results of our analysis in detail.

DOD guidance states that beneficiaries should have a choice of health  care providers that is sufficient to ensure access to appropriate, high- quality health care. In addition, Standards for Internal Control in the  Federal Government require the use of quality information that is  appropriate, current, complete, accurate, accessible, and timely to inform  decisions. Such standards also require that an agency’s management  define objectives clearly to enable the identification of risk and risk  tolerances, to include defining objectives in specific and measurable  terms to allow for the assessment of performance toward achieving  objectives. Applied to DOD’s analysis of civilian health care available in  proximity to MTFs, such information would include (1) health care quality  and (2) accurate and complete access-to-care data for civilian providers  identified in its assessments.

DOD’s assessments were missing complete and accurate information  about the adequacy of purchased care through civilian health care  providers because 703 Work Group officials stated that their analyses  were detailed enough for the purposes of decision-making about  restructuring. Furthermore, they stated that they plan to “test” the  purchased-care networks of civilian providers during the transition of  MTFs to their restructured end states. Officials stated they believe such a  test will reveal that the supply of providers will increase over time to meet  an increased demand for care from DOD beneficiaries.

However, recent research has reported concerns about growing  nationwide shortages of physicians, including primary care providers—a  type of civilian health care provider that will be in high demand from DOD  beneficiaries as MTFs restructure. For example, a 2019 study projected  physician demand will continue to grow faster than supply, leading to a  projected nationwide shortfall of between 46,900 and 121,900 physicians  by 2032. DOD officials stated they expect to monitor health care quality  and patients’ access during the implementation of MTF transitions. While  this will be a positive step, a better understanding of the quality of civilian  health care providers and patients’ access to an adequate supply of such  providers within drive-time standards could help DOD in its  implementation planning for MTF transitions and its tests of network  capabilities by illustrating areas of highest risk. Until DOD consistently  captures and assesses information about the quality of available civilian  health care and the extent to which such care has met and will continue  to meet patients’ access standards, DOD leaders may not fully  understand risks to the achievement of their objectives in restructuring  future MTFs.

Cost-Effectiveness Assessments Based on a Single Set of Assumptions

DOD applied a single set of assumptions in comparing the cost- effectiveness of direct care delivered at MTFs to that of purchased care,  as previously discussed. On the basis of our analysis of the assumptions  and related data elements, and interviews with DOD officials, we found  that the assumptions do not account for uncertainties that could affect  conclusions about an MTF’s cost-effectiveness. Specifically, DOD made  assumptions about the costs of military personnel salaries, the workload  performed at MTFs, and the reimbursement rates for TRICARE that  individually and collectively likely result in the underestimation of the cost- effectiveness of MTFs, as described in more detail below.

Including the full cost of military medical personnel does not  account for their value outside of MTFs in support of military  operations. DOD included the full cost of active-duty medical  personnel salaries when calculating the unit-level cost of MTF health  care. This approach assumed that military personnel spend all their  time in MTFs. However, military personnel who staff MTFs sometimes  spend half or more of their time contributing to other military work  activities, according to MHS officials. These personnel are essential  for military operations outside the MTFs. Accordingly, DOD referred to  its medical personnel as a “fixed cost” in the Modernization Study. In  its interim report to Congress for section 721 of the NDAA for Fiscal  Year 2017, DOD determined that about 111,000 active-duty personnel  are essential to support its war plans as part of the operational  medical force. By including the full cost of military personnel salaries  in calculations of the unit-level cost of MTF-provided care, DOD has  likely underestimated the cost-effectiveness of MTFs given the dual  purpose of active-duty medical personnel who staff MTFs but spend  time on other military duties and deploy to support operations.  According to MTF officials, some portion of the cost of military  personnel salaries could be considered an approximation of the “cost  of medical force readiness” for the wartime mission, though an  imperfect one.

Units of health care may underreport workload performed at  MTFs. DOD calculated the cost of delivering a single unit (e.g.,  wRVU), of care at its MTFs. Doing so likely underestimates the cost- effectiveness of MTFs given concerns that wRVUs may be  underreported. MTF officials at all 11 locations and 703 Work Group  members agreed that wRVUs are likely underreported within MTFs for  various reasons. For example, some MTF services are not recorded  in wRVUs, such as telehealth consultations, which comprise a  growing share of patient encounters, according to MTF officials. In  addition, in February 2019 we reported that source data for DOD’s  clinical readiness metric for physicians—the same data MTFs use to  record wRVUs—had not passed DOD audits for at least 3 years.  Likewise, in April 2016, we reported concerns that providers’ workload  at MTFs was not being accurately recorded.

TRICARE reimbursement rates for purchased care will likely  need to increase. In comparing the cost-effectiveness of direct care  at MTFs to purchased care from civilian providers in the TRICARE  networks, DOD applied current TRICARE reimbursement rates in its  calculations. MTF and 703 Work Group officials, along with senior  MHS leaders, agreed that DOD may need to pay higher  reimbursement rates in the future to attract new, quality network  providers as its reliance on purchased care for beneficiaries increases  in proportion to the decrease in access to health care services at  many MTFs. In addition, MTF officials and MHS leaders stated that  utilization of some purchased-care services from civilian providers  may be higher than utilization of like services at MTFs because  civilian providers are not incentivized to manage health services and  costs the way the MHS does. This means that the cost of purchased  care could increase by more than expected if utilization rates  increase. For example, a research study completed in 2017 found that  an estimated 21 percent of purchased medical care in the United  States is attributed to unnecessary costs associated with  overtreatment. In 2010, the Institute of Medicine reported that  unnecessary services are the largest contributor to waste in the U.S.  health care system, and could have accounted for about $210 billion  in excess spending in 2009.

By applying a single set of assumptions as described above, DOD’s  assessment of the cost-effectiveness of MTFs was not consistent with a  key practice in economic analysis. Our assessment methodology for  economic analysis states that a sensitivity analysis is an essential  element of a high-quality analysis of cost-effectiveness. Likewise, a  DOD instruction on economic analysis states that analyses of investment  alternatives should include, among other things, a sensitivity analysis,  accounting for uncertainties by testing the sensitivity of the economic  analysis results against various factors. A sensitivity analysis examines  the effects that changes to key assumptions have on the analytic  outcome and are helpful to understanding risk.

To demonstrate the effect of a single set of assumptions versus an  analytical approach that explored other assumptions, we adjusted some  of the assumptions for illustrative purposes. Our analysis found that for  two of seven MTFs we evaluated in detail, changing DOD’s assumptions  in only one respect—by subtracting military personnel salaries—would  have materially affected DOD’s assessment about whether direct care at  the MTF was more cost-effective than purchased care. Further, if military  personnel salaries are excluded from the assessments and TRICARE  reimbursement rates increase by 5 percent, three of the seven MTFs  would be more cost-effective than purchased care. For illustrative  purposes, figure 2 shows how alternative assumptions could change both  the data (i.e., costs and wRVUs) and the results of the assessments as to  whether an MTF is more or less cost effective than purchased care.

According to officials from the 703 Work Group, they did not apply  alternative assumptions to analyze cost-effectiveness because readiness  and the adequacy of civilian health care were more important in their  methodology, and they generally assumed that purchased care is less  costly. However, DOD could still maintain its prioritization sequence while  augmenting its cost-effectiveness analyses with a sensitivity analysis to  help provide more complete information for decision-making and, in the  future, for executing MTF transitions. Without doing so, DOD leaders may  further jeopardize their understanding of risks to the achievement of their  objectives in restructuring future MTFs.

DOD Is Not Yet Well Positioned to Execute MTF Restructuring Transitions

Through its section 703(d) Plan to Congress, DOD has identified actions  that will be needed to facilitate MTF restructuring. These actions include  17 recommendations for enterprise-wide changes across MTFs, and  various MTF-specific steps to mitigate risks at a local level. However,  DOD’s Plan also poses challenges for the military departments and the  DHA related to medical provider readiness and MTF staffing. DOD does  not have a process for monitoring MTF restructuring transitions to  address these challenges.

DOD Has Identified Collective and Specific Actions to Facilitate MTF Restructuring

Through its Plan, DOD has taken preliminary steps toward transition  planning by identifying actions needed to facilitate the restructuring and  MTF transitions. Specifically, in the Plan DOD (1) recommended certain  actions across the collective enterprise of MTFs to facilitate their  restructure to reduced health-care delivery capabilities, and (2) identified  risks and potential mitigation strategies specific to each MTF identified for  restructuring. According to the Plan and 703 Work Group officials, DOD  will begin to plan these transitions in detail after a congressional review  period is completed in May 2020.

Enterprise-wide actions for transition planning for restructured  MTFs. In its plan, DOD recommended 17 enterprise-wide actions to  facilitate MTF restructuring transitions. The Plan noted that the actions  apply across various installations and MTFs, and were not specific to any  certain region, military service, or population size. According to 703 Work  Group officials, these actions will be critical to the successful transition of  MTFs to their restructured end states. We found that the actions  described in the Plan are interdependent and have implications for  military readiness, the adequacy of civilian health care in proximity to  MTFs, and the cost-effectiveness of MTF health care, which are  discussed throughout our report.

Moreover, we found that the recommendations require actions and  coordination from multiple organizations and stakeholders. For example,  the Plan recommends structuring health care operations to support  patients from the military’s Exceptional Family Member Program in  relevant markets. The military departments are responsible for oversight  of this Program, and their coordination with the DHA, MTF officials, and  with military commands will be needed to ensure those patients’ medical  needs are met. This and the other 16 actions are listed below in table 3,  along with the stakeholders who may be needed to implement them.

MTF-specific actions for transition planning. A second step the 703  Work Group has taken toward preliminary transition planning is to identify,  for each MTF, certain salient risks and potential mitigation strategies. The  Work Group documented these risks and mitigations in the “Use Case”  for each MTF, which are included in appendices to the Plan. The “Use  Cases” summarize, among other things, the recommended restructuring  actions and the related analytical basis. Specifically, the “Use Cases” list  risks and related mitigation strategies, noting that the lists summarize  observations from the Work Group’s analyses but are not exhaustive. For  some risks, the “Use Cases” noted that a mitigation strategy should be  determined later. For example, a risk associated with patients’ changes in  expectations—from getting health care at the MTF to getting care outside  the base (from a civilian provider)— will need to be monitored and  managed.

Other risks and mitigation strategies identified in the MTF “Use Cases”  are specific to an MTF’s concerns based on local considerations, such as  the health care services they deliver, the type of active-duty population  they serve, and their knowledge of the nearby civilian health care  providers. For example, at Langley Air Force Base, where DOD is  recommending that the hospital transition to an ambulatory surgery center  (which would not have inpatient care or an emergency room), the “Use  Case” for the MTF notes that the elimination of inpatient capabilities  would decrease the MTF’s support to readiness. This means that future  numbers and types of patients and health care services delivered at  Langley’s MTF, once it becomes an ambulatory surgery center, may not  sustain the clinical readiness requirements of the active-duty medical  personnel assigned to work there—requirements that they must meet for  deployments. Accordingly, the “Use Case” notes that a related mitigation  strategy would create partnerships across area hospitals where Langley’s  medical personnel may be able to supplement their MTF workload and  maintain their readiness.

As another example, the “Use Case” for Fort Polk’s MTF in Louisiana— where DOD is recommending the MTF maintain inpatient care in the short  term but monitor the expansion of local hospitals to determine when  inpatient services can be replaced with purchased care—noted several  specific risks related to patients’ access to care given the remote, rural  location. One risk pertains to labor and deliveries, and the “Use Case”  noted that the two nearest off-base hospitals in the TRICARE network  have had problems with fiscal solvency and there is an insufficient  number of obstetricians. Accordingly, DOD’s mitigation plan is for the  MTF to initially maintain pre- and postnatal care services to expectant  mothers, while (1) monitoring the TRICARE network hospitals and (2)  ensuring the MTF’s obstetricians have privileges at those hospitals for  labor and delivery until the number of network obstetricians is sufficient.

DOD Does Not Have a Process for Monitoring Restructuring Transitions to Address Challenges Challenges for Military Departments and DHA Related to Medical Providers’ Readiness and MTF Staffing

Despite DOD’s preliminary steps toward transition planning, including the  mitigation strategies for risks previously discussed, its Plan poses other  challenges for the military departments and the DHA in executing MTF  restructuring. In particular, our review highlighted two interrelated  challenges with respect to medical providers’ clinical readiness and MTF  staffing levels.

Military departments’ efforts to maintain the clinical readiness of  primary care and nonphysician medical providers. As discussed  earlier in this report, MTF officials stated that MTFs that restructure will  not likely present the diverse and complex medical conditions needed to  sustain the readiness of military primary care and nonphysician providers.  A senior enlisted leader at one MTF observed that the staff would “have  to be creative” to find the right mix of opportunities for enlisted personnel  to gain the clinical experience they need to be ready to deploy as the  clinic transitions to seeing only active-duty patients. MHS leaders we  interviewed agreed with these concerns.

To address MTF and MHS leaders’ concerns, 703 Work Group officials  stated that the MHS would need to develop better metrics for primary  care and nonphysician providers’ clinical readiness requirements, as the  MHS has done for combat casualty care physicians. The officials also  stated that another mitigation plan will be to allow MTFs that become  active-duty clinics to diversify the patient population available to providers  by treating some family members and retirees. MTF officials we spoke  with were encouraged that continuing to treat some family members and  retirees could help address the provider readiness shortfalls they believe  are inherent to becoming an active-duty clinic. However, they and senior  MHS leaders were concerned about the prospect of differentiating among  such beneficiaries in terms of who may be eligible for MTF care at an  active-duty clinic. To that end, officials stated that having the DHA clarify  its roles and responsibilities in executing this flexibility will be a helpful  step.

To address challenges in maintaining the clinical readiness of medical  providers assigned to MTFs that restructure, 703 Work Group officials  stated that existing MHS partnerships with civilian hospitals and the  Department of Veterans Affairs should be sufficient for MTF providers  along with other available mechanisms, such as temporary duty at other  MTFs. However, MHS leaders stated that existing civilian partnerships, in  particular, may not have sufficient capacity to take on additional military  medical personnel. As a result, the leaders believe they may need to  expand partnerships to accommodate the expected increase in demand  from military providers for on-the-job readiness training as MTF  capabilities decrease during restructuring transitions. Furthermore, MTF  officials we interviewed had mixed opinions about the readiness benefits  they derived from their experiences with civilian hospital partnerships and  training at other MTFs.

DHA and the military departments’ ability to fully staff the MTFs.  According to MTF officials, sending their medical providers to work  outside their assigned MTF in support of clinical readiness, though  temporary, creates another challenge by reducing providers’ availability to  the MTFs. As more providers require such experience due to MTF  capabilities’ decrease from restructuring, MTF officials we interviewed  noted that staffing gaps could complicate their ability to execute the  transitions and ensure the continuity of care for patients. Furthermore,  MTF officials stated that active-duty medical personnel reductions that  occurred in fiscal year 2019 have also created shortfalls in staffing that  could pose challenges for them in executing the MTFs’ transitions.  According to these officials, this is because they expect their  administrative workload to increase while transitions are ongoing, while  clinical workload for patient care would not decrease soon enough to  mitigate any shortfalls in providers.

DOD’s Plan states that the DHA should collaborate with the military  departments to establish standard staffing models to facilitate MTF  transitions, and transition plans must specify reductions in personnel and  resources for the future state of the MTFs. However, the continuation of a  phased transfer of MTF administration and management to the DHA from  the military departments may present challenges to the DHA’s ability to  concurrently accomplish new tasks related to restructuring the MTFs and  facilitating their transitions. Likewise and more broadly, we reported in  November 2018 that the transfer of MTF administration and management  to the DHA may present challenges to the management of military  personnel given that the military departments are responsible for medical  personnel readiness, not the DHA, while DHA assumes responsibility for  staffing the MTFs.

No Process for Monitoring MTF Restructuring Transitions

DOD has not established a process for monitoring MTF restructuring  transitions to address the aforementioned challenges. Yet, the MHS plans  to move forward with restructuring actions beginning in June 2020. While  officials expect that transitions of certain smaller clinics to their  restructured end state may be relatively simple, they acknowledged that  other MTF transitions could be complex and take several years.  According to the ASD(HA) and Work Group officials, DOD will readjust its  plans by reversing or slowing an MTF transition, if needed, to address  any challenges that arise with ensuring patients’ ability to access health  care—one of the restructuring objectives. DOD’s Plan does not discuss  conditions that would warrant slowing or reversing an MTF’s restructure,  or how that would be determined. According to senior MHS leaders and  MTF officials, the potential need to reverse or slow transitions will make  monitoring the transitions important, and they are awaiting such  decisions, along with associated roles and responsibilities from the DHA.

However, the Plan does not establish a process for monitoring MTF  restructuring transitions, as this was not within the scope of efforts,  according to 703 Work Group officials. Rather, officials stated that  decisions about monitoring should occur in a next phase of execution for  MTF transitions after completion of the Plan. Accordingly, after DOD  submitted its Plan to Congress in February 2020, the ASD(HA) issued a  memorandum tasking the Director of the DHA to implement the changes  specified in the Plan (i.e., the MTF restructuring actions) and providing  high-level guidance. For example, the memorandum states that:

MTF transitions are not authorized to start before May 19, 2020 (i.e.,  90 days after the Plan was provided to Congress) but should be  completed no later than October 1, 2025;  transition planning may begin at the DHA Director’s discretion (but not  later than the beginning of fiscal year 2021) and should include all  impacts from ongoing personnel reductions and realignments; and detailed transition plans should include clear mechanisms for  stakeholder tracking of activities and progress, and be arranged in a  manner that addresses the needs of multiple stakeholders from the  local to the national levels.

Regarding the transition plans, the memorandum requested that that the  DHA Director provide the ASD(HA) with a point of contact within 5 days,  and a timeline, milestones, initial resource requirements, and task  organization for the effort within 2 weeks—i.e., by February 26 and March  6, 2020, respectively. The DHA missed these milestones, having not yet  provided the requested information, although an official from the Office of  the ASD(HA) stated that, as of March 2020, the DHA response was being  drafted.

MHS reform and the DHA’s progress in achieving goals are longstanding  challenges on which we have previously reported. In April 2012, before  the DHA was established, we reported that DOD did not consistently  employ key management practices in implementing initiatives to change  its MHS governance structure. We recommended that the ASD(HA) and  the Surgeons General implement a monitoring process across DOD’s  portfolio of initiatives for overseeing progress and identify accountable officials and their roles and responsibilities for all of its initiatives. DOD  implemented this recommendation by assigning each initiative a working  group, an initiative leader, and executive sponsor to help ensure that the  initiative remained on schedule, on budget, and achieved performance  goals. After DOD established the DHA, we reported in November 2013  and later in September 2015 on its progress. In both reports, we  identified deficiencies and made recommendations to provide decision  makers with more complete information on the implementation,  management, and oversight of the DHA. DOD concurred with the 10  related recommendations and implemented all but one.

We reported in March 2004 that a process for monitoring progress is key  to successful results-oriented management. However, DOD does not  have such a process for the MTF restructuring transitions, in part because  MHS officials stated they would first need to establish detailed roles and  responsibilities for executing the transitions generally. Beyond the DHA  Director’s role of transition leader, other roles and responsibilities have  not been established, such as what involvement MTF officials will have in  monitoring and tracking progress or challenges, and how the military  departments will share responsibilities with the DHA. The Senior Military  Medical Advisory Council could sufficiently monitor the transitions at a  high level, according to the DHA Director. Other MHS leaders we spoke  with believed that involvement from additional military department and  Office of the Secretary of Defense leaders could also be needed.

As we reported in October 2005, agreement on roles and responsibilities  is a key step to successful collaboration when working across  organizational boundaries, such as the military services. Committed  leadership by those involved in the collaborative effort, from all levels of  the organization, is needed to overcome the many barriers to working  across organizational boundaries. Our prior work has also shown that a  dedicated team vested with necessary authority and resources to help set  priorities, make timely decisions, and move quickly to implement  decisions is critical for a successful transformation.

DOD also has not defined objectives in a measurable way with related  thresholds and goals to enable monitoring of progress and challenges.  For example, as previously discussed, DOD’s three general priorities, or  objectives, for restructuring MTFs include ensuring (1) the medical  readiness of servicemembers and readiness of medical providers, (2) that  civilian health care facilities and providers adequately support the health  care needs of beneficiaries near each MTF, and (3) the cost-effectiveness  of MTF and purchased care. However, DOD has not decided how to  define and measure any of those objectives. Furthermore, DOD has not  established thresholds or goals in relation to the objectives.

By first establishing clear roles and responsibilities for executing and  monitoring restructuring transitions, DOD can be better positioned to  navigate and overcome organizational boundaries between the DHA,  which manages the MTFs, and the military departments that provide staff.  In doing so, DOD could also be better positioned to address challenges in  executing transitions, such as those that arise with mitigating providers’  clinical readiness challenges and MTF staffing gaps during transitions.  Then, by defining measurable objectives, goals, and thresholds for  tracking the progress of MTF transitions—such as the clinical readiness  of providers, quality and accessibility of quality health care, and cost- effectiveness—DOD could better ensure its objectives are being met and  help facilitate timely adjustments to the transitions, as needed.

As MHS leaders have acknowledged, correctly aligning MTF  infrastructure to the size of the armed forces, the medical forces, and their  desired readiness levels is essential to balancing mission requirements  within available resources. DOD’s substantial work over the past 2 years  on its Plan for MTF restructuring is a positive step toward meeting  statutory requirements and prioritizing MTF readiness outcomes in a  resource-informed manner. Notwithstanding the work DOD has  undertaken in making a series of analytically-based determinations for  restructuring in its Plan, our review highlighted several gaps in DOD’s  methodology. Until DOD takes action to address these gaps by using  more complete and accurate information about civilian health care quality,  access, and cost-effectiveness, DOD leaders may not fully understand  risks to the achievement of their objectives in restructuring future MTFs.

DOD officials agree that some MTF restructuring actions may be more  challenging than others. These challenges could be exacerbated by  concurrent MHS reform efforts, including the transition of MTF  administration and management to the DHA. However, by establishing  clear roles and responsibilities for executing and monitoring the  transitions, DOD can be better positioned to overcome the difficulties in  navigating organizational boundaries between the DHA and the military  departments, and make timely adjustments to their transition plans, as  needed. In addition, by defining measurable objectives, thresholds, and  goals for restructuring transitions, and applying them to evaluate progress  and challenges, DOD can be better positioned to execute the transition of  its MTFs and ensure that the objectives are being met.

We are making the following six recommendations to DOD:  The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the Surgeons General of  the military departments and the Director of the DHA, consistently collect  complete and accurate information about the quality of available civilian  health care in proximity to its MTFs (such as ratings from the Centers for  Medicare and Medicaid Services and perceptions from MTF officials who  regularly coordinate with civilian providers, among other means) and  assess that information to inform recommendations for future MTF  restructuring decisions. (Recommendation 1)

The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the Surgeons General of  the military departments and the Director of the DHA, consistently collect  complete and accurate information about the extent to which current  health care providers within the TRICARE networks meet access-to-care  standards, and assess that information to inform recommendations on  future MTF restructuring decisions. (Recommendation 2)

The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the Surgeons General of  the military departments and the Director of the DHA, consistently collect  complete and accurate information about the extent to which non-network  civilian health care providers that could be incorporated into the TRICARE  network meet access-to-care standards in terms of drive time, and assess  that information to inform recommendations on future MTF restructuring  decisions. (Recommendation 3)

The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the Surgeons General of  the military departments and the Director of the DHA, conducts a  sensitivity analysis of the relative cost-effectiveness of MTF-provided care  compared to civilian-provided care under varying assumptions, and  document that information for decision makers to inform  recommendations on future MTF restructuring decisions. Varying  conditions could include different types of health care services, reducing  the cost of military personnel salaries, and increasing estimated MTF  wRVUs and civilian reimbursement rates. (Recommendation 4)

The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the Surgeons General of  the military departments and the Director of the DHA, establishes clear  roles and responsibilities for executing and monitoring transitions for  MTFs identified for restructuring. (Recommendation 5)

The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the Surgeons General of  the military departments and the Director of the DHA, defines measurable  objectives for MTF restructuring transitions, establishes thresholds and  goals for each objective, and applies them to evaluate progress and  challenges. For example, measurable objectives, thresholds, and goals,  should include an evaluation of medical providers’ clinical readiness,  civilian health care provider adequacy, and the cost-effectiveness of MTF  and purchased care. (Recommendation 6)

We provided a draft of this report to DOD for review and comment. In its  written comments, reproduced in appendix IV, DOD concurred with two of  our recommendations and partially concurred with four recommendations.  DOD also provided technical comments on the draft report, which we  incorporated as appropriate.

DOD concurred with our recommendations to establish roles and  responsibilities for executing and monitoring MTF restructuring transitions  (recommendation 5), and to define measurable objectives with thresholds  and goals and apply them to evaluate progress and challenges for the  transitions (recommendation 6). In its response, the department  described actions it is taking and plans to take to implement both  recommendations.

DOD partially concurred with our first recommendation—to collect  complete and accurate information about the quality of available civilian  health care in proximity to its MTFs and assess that information to inform  recommendations for future MTF restructuring. DOD stated that complete  and accurate information on the quality of available care would require  substantial resources to accomplish on a routine basis. To that end, DOD  stated that until standardized quality data becomes readily available, it  intends to collect this level of information as needed to support actions at  a particular MTF. As noted in our report, we have previously reported that  standardized information about hospital and outpatient care quality is  available through the Centers for Medicare & Medicaid Services and has  been widely adopted by major private insurers. As the restructuring of the  MTFs continues and DOD relies to a greater extent on civilian-provided  care, it will be important for the department to monitor the quality of care it  purchases on behalf of beneficiaries. Thus, we continue to believe that  DOD should make it a priority to collect and assess such information.

DOD partially concurred with our second recommendation—to  consistently collect complete and accurate information about the extent to  which current health care providers within the TRICARE networks meet  access-to-care standards, and assess that information to inform  recommendations on future MTF restructuring decisions. In its response,  DOD stated that each month, TRICARE contractors report, by specialty,  average wait times from referral placement to patient appointment.  Further, DOD stated that it is piloting centralized booking of MTF and  network appointments, which, if successful, will result in more complete,  accurate, and timely network access information. In cases where access  standards are not being met, DOD explained that it works to mitigate the  access shortfall either through MTF or expanded network resources.

We agree that TRICARE’s monthly reports on patient wait times for  appointments are a helpful tool for DOD in monitoring access to care, and  that the pilot for centralized appointment booking is also a promising step.  As we noted in our report, however, DOD’s analyses of the adequacy of  civilian health care in proximity to MTFs were based on network provider  directories that are of questionable accuracy and can overstate the  number of available providers. MTF officials we interviewed stated that  TRICARE directories in their area overstated the number of providers  accepting new TRICARE patients.

Even if the provider directory issues have not led to access-to-care  challenges in the past in terms of patients’ wait times to appointments,  such issues could cause challenges in the future with increasing numbers  of DOD patients needing TRICARE network care. Accordingly, we  continue to believe that it will be important for DOD to collect complete  and accurate information about the extent to which current health care  providers within the TRICARE networks meet access-to-care standards  as DOD moves forward with its restructuring plans.

DOD partially concurred with our third recommendation—to consistently  collect complete and accurate information about the extent to which non- network civilian health care providers that could be incorporated into the  TRICARE network meet access-to-care standards in terms of drive time,  and assess that information to inform recommendations on future MTF  restructuring decisions. DOD stated that drive times for non-network  providers were assessed in the development of the recommendations for  its Plan. DOD added that the approach used in the Plan included  assessing drive times and distances from the beneficiaries’ homes, rather  than the MTF, yielding a more accurate assessment of access,  availability, and convenience.

However, our review of DOD’s methodology workpapers showed that its  analyses measured the distance between providers and a single location  point that corresponds with the center of the zip code boundary in which a  majority of beneficiaries reside. While a perfect methodology and  information for projecting actual drive times may not be possible to  achieve, the alternative method in our report illustrates that a portion of  the providers DOD identified for potential network expansion would  exceed access-to-care standards for some of its beneficiaries—especially  those who live or work near an MTF (such as those who live on a military  installation). According to DOD’s comments on the report, future  restructuring efforts will be informed by the section 703 approach, and  DOD will adjust the approach as needed by future analysis and  conditions. As DOD moves forward with restructuring efforts in the future,  we continue to believe that more accurately measuring the distance  between providers’ locations and beneficiaries’ residences would improve  the quality of DOD’s information about access-to-care. Accordingly, we  continue to believe that DOD should fully implement our recommendation.

DOD partially concurred with our fourth recommendation—to conduct a  sensitivity analysis of the relative cost-effectiveness of MTF-provided care  compared to civilian-provided care under varying assumptions, and to  document that information for decision makers to inform  recommendations on future MTF restructuring decisions. In response,  DOD stated that there is value in the use of sensitivity or scenario  analysis to inform decisions where a range of possibilities exist and a  clear analytical question can be formed as a guide to both the analysts  and decision-makers. However, DOD stated that it does not support the  generic use of this analysis suggested by the recommendation.

We disagree that our recommendation suggests the “generic use” of a  sensitivity analysis. A sensitivity analysis is appropriate for evaluating  restructuring opportunities for MTFs for two reasons. First, the evaluation  of each MTF presents decision makers with a range of possibilities—from  reducing or expanding the capabilities of an MTF, to closing it entirely or  maintaining the status quo. Second, a sensitivity analysis would address  uncertainties in DOD’s analytic assumptions about costs and workload for  each MTF, which our report identified.  As our own sensitivity analysis— conducted using minimal resources and available DOD data— demonstrated, changing the assumptions also changes the resulting  conclusions about whether MTF or civilian care is less expensive.  Therefore, we continue to believe that analyzing the relative cost- effectiveness of MTF-provided care compared to civilian-provided care  under varying assumptions would provide more complete information for  decision-making and executing MTF transitions.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Under Secretary of Defense  for Personnel and Readiness, the Assistant Secretary of Defense for  Health Affairs, the Director of the Defense Health Agency, and the  Secretaries of the Army, the Navy, and the Air Force. In addition, the  report is 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  me at (202) 512-3604 or farrellb@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last   page of this report. GAO staff who made key contributions to this report  are listed in appendix V.

Appendix I: Objectives, Scope, and Methodology

In February 2020, the Department of Defense (DOD) submitted its  implementation plan (“the Plan”) to Congress in response to section  703(d) of the National Defense Authorization Act (NDAA) for Fiscal Year  2017. This report addresses the extent to which (1) DOD’s methodology  for determining military medical treatment facility (MTF) restructuring  actions in the Plan prioritized cross-cutting elements from 10 U.S.C. §  1073d and considered complete information, and (2) DOD has positioned  itself to execute transition planning for restructuring its MTFs.

For both objectives, we selected a nongeneralizable sample of MTFs and  applied a case study approach to review DOD’s methodology for  determining restructuring actions and actions that may be needed for  transition planning. From DOD’s initial list of 73 MTFs included in its  scope, we selected 11 of them as case studies to represent a variety of  characteristics, including a mix of hospitals and clinics from each military  department, different recommendations for how they should be  restructured, different conclusions about network adequacy, and urban  and rural areas located in proximity to one another in terms of driving  distance. Appendix II identifies the names and locations of each MTF  within the scope of the DOD Plan. The 11 MTFs we selected are listed in  table 4.

For objective one, we reviewed DOD’s draft and final Plan and related  documentation of the methodologies used to assess all 77 MTFs within its  scope. We compared this information with cross-cutting elements for  MTFs from 10 U.S.C. § 1073d. These elements include the (1) support  an MTF provides to servicemembers’ medical readiness and the  readiness of medical personnel, (2) adequacy of civilian health care  facilities and providers in the proximity of the MTF to support the health  care needs of servicemembers and other beneficiaries through purchased  care, and (3) cost-effectiveness of direct care services at MTFs versus  purchased care in the nearby civilian provider networks.

We discussed the methodological approaches for assessing MTFs for  possible restructuring actions, including assumptions, data sources, and  any limitations, with representatives from relevant organizations across  DOD, including the Office of the Assistant Secretary of Defense for Health  Affairs; DOD’s Section 703 Work Group; Defense Health Agency; Office  of the Assistant Secretary of the Army for Manpower and Reserve Affairs;  U.S. Army Medical Command; Navy Bureau of Medicine; Air Force  Medical Readiness Agency; and officials from 11 selected MTFs and from  their host installations.

Specifically, in analyzing DOD’s methodology for assessing MTFs’  support to readiness, we reviewed information DOD used to estimate  MTFs’ readiness value in terms of support to servicemembers’ medical  readiness and to medical force readiness. We compared this information  with findings from our prior work regarding DOD’s methodology for  assessing clinical readiness. We also reviewed records of interviews that  DOD officials held with MTF, installation, and command officials during  their visits to MTFs, noting the readiness-related effects and concerns  that were documented.

For DOD’s methodology for assessing available civilian health care  services in proximity to each MTF, we reviewed reports on the results of  DOD’s assessments to identify their findings, recommendations, and  assumptions. For the civilian health care providers that DOD identified in  proximity to each of 11 MTFs we selected, we verified the address of  each listed provider by searching for each provider’s website and making  phone calls to verify addresses and specialty types, and whether the  practice was open or closed. We then used R software and data from  openstreetmap.org to calculate to calculate the driving distance between  the provider and the MTF, comparing the distance with DOD’s access-to- care standards. We evaluated the extent to which the assessment  reports considered information about quality of health care services and  access-to-care standards, comparing the information with DOD guidance  for patients’ access to quality and timely health care services, and with  federal internal control standards on the use of quality information to  inform decision-making.

Regarding DOD’s methodology for evaluating cost-effectiveness, we  reviewed DOD’s work papers and interviewed officials about the  calculations and source data they used. We compared DOD’s  methodology with our assessment methodology for economic analysis  and with DOD guidance for economic analysis. We also obtained the  fiscal years 2017 and 2018 data DOD used to calculate the cost- effectiveness of MTF-provided direct care relative to civilian-provided  purchased care. Using these data, we performed a sensitivity analysis by  recalculating relative cost-effectiveness under different assumptions.  Specifically, for seven of our 11 case study MTFs, we recalculated their  cost-effectiveness relative to purchased care by (1) omitting military  personnel salaries, given that DOD has characterized these as a fixed  cost, (2) increasing the work Relative Value Units to adjust for potential  underreporting of those data, and (3) increasing the reimbursement rate  of purchased care to account for future increases that are likely  necessary, according to DOD officials. We also assessed the reliability of  each data source for DOD’s and our calculations of cost-effectiveness by  administering questionnaires about the data to those who have quality  control responsibilities, interviewing responsible DOD officials, reviewing  the data for outliers and missing values, and reviewing our prior reports  about the data. We determined that DOD’s data on the costs of MTF  care and civilian health care were sufficiently reliable for the purpose of  calculating the total costs of health care services. However, DOD’s data  on units of health care delivered in fiscal year 2018 were of undetermined  reliability for the purpose of calculating a unit-level health care cost.

To provide additional information on DOD’s methodology and supplement  our understanding of available data, we conducted a literature review of  research articles. We conducted a search of the literature on military  health system clinical readiness, trends in physician supply and demand  across the United States, and cost analyses of military health care  published from 2014 through 2019 to identify articles on key challenges  and methodological alternatives. To identify relevant articles, we  searched a variety of databases with the assistance of a research  librarian, limiting our review to papers that were included in peer-reviewed  publications, as well as government reports, trade and industry articles,  and publications by associations, nonprofits, or think tanks. We then  reviewed the results and excluded any that were technical in nature or did  not have wide applicability across MTFs or to health care analyses.

For objective two, we reviewed DOD’s draft and final Plan, including  detailed appendices on the MTFs within the scope of the plan, noting any  aspects of transition planning described or recommended, and the  agencies and organizations that would be responsible for managing those  transition aspects. We also interviewed MTF officials from the selected  case study locations regarding steps they had begun taking and actions  they believed would be needed to facilitate a restructuring of the facility.  In addition, we reviewed our prior, related work on MHS reform and the  establishment of the Defense Health Agency to identify related themes  and challenges.

We corroborated our understanding of transition planning steps described  in the Plan by interviewing 703 Work Group officials, the Director of the  Defense Health Agency, and the Surgeons General of the Army and the  Air Force to better understand what roles and responsibilities and  monitoring mechanisms they had considered. We compared this  information from the Plan and from our interviews with practices identified  in our prior work on results-oriented government. Specifically, our prior  work has found that agreement on roles and responsibilities and  committed leadership by those involved are key steps to successful  collaboration when working across organizational boundaries. A  dedicated team vested with necessary authority and resources to help set  priorities, make timely decisions, and move quickly to implement  decisions, along with a process for monitoring progress, are also key to  success.

Finally, to assess the extent to which DOD’s section 703(d) Plan  addressed all requirements of section 703(d), we compared the Plan with  the elements from the statute. Examples of those elements included, for  each MTF, whether it will be restructured, whether its functions will be  expanded or consolidated, and the related costs. Some of the elements  required that multiple items be addressed. We considered an element  “addressed” if it included all of the items listed in the NDAA; “partially  addressed” if it included some, but not all, of the items; and “not  addressed” if it did not include any of the items.

We conducted this performance audit from February 2019 to May 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.

Appendix II: Locations of Military Medical Treatment Facilities within the Scope of DOD's Section 703(d) Plan on Restructuring

A work group of representatives from across the Department of Defense  (DOD) led efforts to address section 703(d) of the National Defense  Authorization Act for Fiscal Year 2017—the restructure or realignment of  military medical treatment facilities (MTF). The 703 Work Group  developed a methodology to address section 703(d) and determined the  scope of its review of MTFs in the United States by identifying which of  those to evaluate for the mandated implementation plan (the “Plan”).  Figures 3 through 5 below identify the name and location of each of the  77 MTFs within the scope of DOD’s Plan, which it submitted to Congress  in February 2020.

Appendix III: Distances from Military Medical Treatment Facilities to Civilian Providers Identified in DOD Assessments

The Department of Defense’s (DOD) 703 Work Group based its military  medical treatment facility (MTF) restructuring determinations for its  implementation plan to Congress, in part, on its assessments of the  adequacy of civilian health care facilities and providers to support the  health care needs of DOD beneficiaries near each MTF. In one  component of the assessments, DOD identified civilian health care  facilities and providers in proximity to each of its 77 evaluated MTFs.

For each provider DOD identified in proximity to 11 MTFs—which we  selected from the 77 MTFs DOD evaluated—we verified the provider’s  address, specialty type, and whether the practice was open or closed. We  then calculated the driving distance between each MTF and the  respective listed providers. Figures 6 through 16 below show that a  certain portion of the providers listed for each of the 11 selected MTFs  were outside DOD’s access-to-care standards for travel time to provider  sites for TRICARE Prime patients, based on our analysis. In addition, for  each of the 11 selected MTFs, there was one or more inaccuracies in the  provider listing, such providers that were no longer in practice, duplicate  providers, or those that were mischaracterized as a medical provider.

Appendix IV: Comments from the Department of Defense

Appendix V: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Lori Atkinson (Assistant Director),  Melissa Blanco (Analyst in Charge), John Beauchamp, Timothy Carr,  Alexandra Gonzalez, Hannah Hubbard, David Jones, Amie Lesser, John  Mingus, Jr., Oliver Richard, Terry Richardson, Guiovany (Geo) Venegas,  and Lillian M. Yob made key contributions to this report.

Defense Health Care: Opportunities to Improve Future TRICARE  Managed Care Support Contract Transitions. GAO-20-39. Washington,  D.C.: November 21, 2019.

Defense Health Care: DOD’s Proposed Plan for Oversight of Graduate  Medical Education Programs. GAO-19-338. Washington, D.C.: March 28,  2019.

Defense Health Care: Actions Needed to Determine the Required Size  and Readiness of Operational Medical and Dental Forces.  GAO-19-206. Washington, D.C.: February 21, 2019  Defense Health Care: Additional Assessments Needed to Better Ensure  an Efficient Total Workforce. GAO-19-102. Washington, D.C.: November  27, 2018.

Defense Health Care: DOD Should Demonstrate How Its Plan to Transfer  the Administration of Military Treatment Facilities Will Improve Efficiency.  GAO-19-53. Washington, D.C.: October 30, 2018.

Defense Health Care: Expanded Use of Quality Measures Could  Enhance Oversight of Provider Performance. GAO-18-574. Washington,  D.C.: September 17, 2018.

Defense Health Reform: Steps Taken to Plan the Transfer of the  Administration of the Military Treatment Facilities to the Defense Health  Agency, but Work Remains to Finalize the Plan. GAO-17-791R.  Washington, D.C.: September 29, 2017.

Defense Health Care Reform: DOD Needs Further Analysis of the Size,  Readiness, and Efficiency of the Medical Force. GAO-16-820.  Washington, D.C.: September 21, 2016.

Defense Health Care Reform: Actions Needed to Help Ensure Defense  Health Agency Maintains Implementation Progress. GAO-15-759.  Washington, D.C.: September 10, 2015.

Military Health System: Sustained Senior Leadership Needed to Fully  Develop Plans for Achieving Cost Savings. GAO-14-396T. Washington,  D.C.: February 26, 2014.

Defense Health Care Reform: Additional Implementation Details Would  Increase Transparency of DOD’s Plans and Enhance Accountability.  GAO-14-49. Washington, D.C.: November 6, 2013.

Defense Health Care Reform: Applying Key Management Practices  Should Help Achieve Efficiencies within the Military Health System.  GAO-12-224. Washington, D.C.: April 12, 2012.

Military Personnel: Enhanced Collaboration and Process Improvements  Needed for Determining Military Treatment Facility Medical Personnel  Requirements. GAO-10-696. Washington, D.C.: July 29, 2010.

About 9.6 million beneficiaries are eligible for Defense Department health care from Medical Treatment Facilities and TRICARE civilian providers. DOD issued a plan in February for a required restructure of Medical Treatment Facilities, which called for decreasing capability at 43 of them and closing five.

DOD’s restructuring review included required elements, such as assessing the adequacy of nearby civilian health care. However, it was based in part on incomplete and inaccurate information and may overstate the adequacy of available care.

We made 6 recommendations, including that DOD use more complete and accurate information in its review.