Defense Health Care: DOD Should Collect and Use Key Information to Make Decisions about Incentives for Physicians and Dentists

DOD invests in a number of incentives to recruit and retain its nearly 15,000 military physicians and dentists, such as providing a tuition-free education to medical and dental students who in return agree to serve as military physicians or dentists for a specific amount of time.

Section 597 of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 included a provision for GAO to review military physicians' and dentists' compensation, among other things. This report addresses, among other objectives, (1) how compensation for military physicians and dentists compared to private sector civilians with comparable skills in 2017, and (2) the extent to which DOD has developed an approach to recruit and retain military physicians and dentists through a package of incentives that reflect key principles of effective human capital management. GAO compared military and civilian cash compensation for 2017—the most recent year of data amongst data sources, assessed incentive packages against key principles of human capital management, and conducted surveys and held focus groups to obtain the perspectives of current military medical students and residents regarding military service obligations.

In 2017, cash compensation for military physicians and dentists in most of the 27 medical and dental specialties GAO reviewed was generally less than the median compensation of private sector civilians, but the Department of Defense (DOD) provides substantial deferred and noncash benefits, such as retirement pensions and tuition-free education, whose value to servicemembers is difficult to determine. GAO found that for 21 of the 27 physician and dental specialties, the maximum cash compensation was less than the private sector civilian median within four officer pay grades (O-3 to O-6) (see figure for number of physician specialties by pay grade). Moreover, cash compensation for military physicians and dentists was less than the private sector civilian median at key retention points, such as after physicians and dentists fulfill their initial active-duty service obligations.

DOD recruits and retains physicians and dentists through a package of incentives, including tuition-free medical or dental school and special and incentive pays, such as multi-year retention bonuses. However, DOD does not consistently collect information related to the following three key principles of effective human capital management to help inform investment decisions in its package of recruitment and retention incentives:

Replacement costs . DOD does not consistently collect information on replacement costs of military physicians and dentists. However, DOD has previously identified replacement costs as a factor in assessing the appropriateness of incentive pays.

Current and historical retention information . DOD does not consistently collect information on retention of physicians and dentists, specifically acceptance rates for retention bonuses, to help assess the effectiveness of these bonuses.

Private sector civilian wages. DOD does not consistently collect information on private sector civilian wages. Officials stated that civilian wages are not a driving factor when considering adjustments to special and incentive pays, in part because DOD cannot always match civilian sector compensation for military physicians and dentists.

By collecting and using this information to help inform its decision-making, DOD would be better positioned to assess the effectiveness of its incentives to recruit and retain military physicians and dentists and make sound investment decisions for the future.

GAO recommends that DOD should collect and use information on (1) replacement costs of military physicians and dentists, (2) retention, and (3) private sector civilian wages to inform its investment decisions. In commenting on a draft of this report, DOD concurred with these recommendations.

In fiscal year 2018, the Department of Defense (DOD) spent over $1.8  billion on special and incentive pay programs, representing compensation  in addition to their basic pay, to incentivize servicemembers for  occupations that are dangerous, less desirable, or require special skills.  Of this $1.8 billion, $710.1 million, or 40 percent of the total, was used to  recruit and retain DOD’s nearly 15,000 active-duty physicians and  dentists. DOD also invests in programs to create a pipeline of future  military physicians and dentists. For example, to educate medical and  dental students in its Health Professions Scholarship Program (the  scholarship program), DOD spent approximately $212 million in fiscal  year 2018. Despite these investments, DOD has faced challenges in  recruiting and retaining the desired number of physicians and dentists in  required critical specialties, including those needed for wartime or  operational deployments. Such challenges include national shortages in  certain specialties and competition with the private sector. Moreover, the  Association of American Medical Colleges projects national shortages to  continue.

DOD’s primary method of meeting its needs for physicians and dentists is  to recruit medical students through the scholarship program and the  Uniformed Services University of the Health Sciences (the University).  DOD pays for recruits’ medical or dental school and provides additional  financial incentives, such as a stipend for its scholarship program  students or salary for those attending the University. In return for this  investment, participants accrue an active-duty service obligation.  Recently, DOD has begun to consider changes to the active-duty service  obligation as a means to address personnel shortages. For example, in  its February 2019 interim report on developing a personnel management  plan for trauma-related wartime medical specialties, DOD stated that  some actions, such as increased service obligations paired with  increased benefits, may be required in order to close the gaps between  authorized and filled positions.

Our recent work reviewing the recruitment and retention of physicians  assessed the extent to which DOD was able to fill its authorized positions.  Specifically, in February 2018 we found that each of the three military  departments experienced gaps for a number of active-duty military  physician specialties, including those considered critically short wartime  specialties. Specifically, we found that DOD’s use of its recruitment and  retention programs was not fully addressing military physician gaps in  certain critical specialties, in part because DOD did not have targeted and  coordinated strategies for reducing such gaps. We recommended that  each of the military departments develop targeted strategies to use their  recruitment and retention programs collectively to address key military  physician gaps in a coordinated manner, and develop metrics to monitor  the effectiveness of their programs in reducing gaps. DOD concurred with  the recommendations and, according to DOD officials, a DOD working  group has been formed to produce a plan by June 2020 to address  recruitment and retention of critical specialties.

We also recently assessed DOD’s recruitment and retention of dentists.  Specifically, in December 2018 we found that the three military  departments experienced gaps in certain dental specialties, including  critically short wartime specialties. Moreover, we reported that while the  military departments rely on incentives such as special pays to recruit and  retain military dentists, they did not know the extent to which some of  these programs have been effective in achieving their goals because they  have not evaluated their effectiveness. We recommended, among other  things, that the military departments ensure that their Surgeons General  evaluate the effectiveness of their respective recruitment and retention  programs for military dentists. DOD concurred with the recommendation  and, according to DOD officials, efforts are underway and a study will be  done to determine the effectiveness of the recruitment and retention  programs for military dentists, including the need for the incentives  currently offered. DOD expects to complete its final report in 2020.

Section 597 of the John S. McCain National Defense Authorization Act for  Fiscal Year 2019 included a provision for us to report on military  physicians’ and dentists’ compensation and the effects of changing  active-duty service obligations for medical and dental education and  residency training by requiring the obligations to be served consecutively,  or one after another. In February 2019, we provided an interim briefing  to the congressional armed services committees; this report transmits the  final results of our work. This report addresses: (1) how compensation for  military physicians and dentists compared to private sector civilians with  comparable skills in 2017; (2) the extent to which DOD has developed an  approach to recruit and retain military physicians and dentists through a  package of incentives that reflect key principles of effective human capital  management; and (3) the perceptions of military medical students,  residents, and DOD officials regarding active-duty service obligations,  including their effect on recruitment and retention.

To address our first objective, we reviewed DOD policy and guidance and  relevant statutes to identify the types of military compensation in 2017. To  compare cash compensation for military physicians and dentists to  comparable private sector civilian specialties, we estimated military cash  compensation using information reported in DOD’s Greenbook  publication and Health Professions Officer Special and Incentive Pay  Plan and compared that to private sector civilian compensation  information reported in surveys from the American Medical Group  Association and American Dental Association. We selected 2017  because it was the most recent year of available data amongst all of our  sources. To determine the reliability and accuracy of private sector civilian  compensation information, we checked these data for reasonableness  and the presence of any obvious or potential errors in accuracy and  completeness. We believe the data are sufficiently reliable for the  purpose of this report. To describe the deferred and noncash benefits  available to military physicians and dentists, we reviewed our reports,  other relevant research, and DOD reports. To develop estimates of the  value of DOD’s two retirement benefit programs, we used DOD’s  publically-available retirement calculators. To help determine the reliability  and accuracy of DOD’s retirement calculators, we checked the data for  reasonableness and the presence of any obvious or potential errors in  accuracy and completeness and interviewed DOD officials  knowledgeable about the data. We believe the data are sufficiently  reliable for the purpose of this report. We also interviewed DOD officials  to confirm our understanding of military cash compensation, and to obtain  their perspectives on our approach to comparing military and private  sector civilian cash compensation and estimating retirement benefit  estimates.

To address our second objective, we reviewed pay plans, policies, and  other documents developed by the Office of the Assistant Secretary of  Defense for Health Affairs (ASD(HA)) and the respective military  departments concerning DOD’s approach to recruitment and retention of  military physicians and dentists. We also interviewed officials from the  Office of the ASD(HA) and the military departments concerning their  decision-making process in managing this package of incentives. We  compared this information with seven key principles of effective human  capital management which we identified in our February 2017 report on  military compensation. As we stated in that report, to identify key  principles of effective human capital management, we reviewed a  compilation of GAO’s body of work on human capital management,  DOD’s Report of the Eleventh Quadrennial Review of Military  Compensation, and the DOD Diversity and Inclusion Strategic Plan 2012  - 2017. In addition to these key principles, we also compared aspects of  DOD’s approach to recruitment and retention of military physicians and  dentists against federal internal control standards, which state  management should use quality information to achieve an entity’s  objectives, and highlighted areas where DOD’s approach differed from  these principles.

To address our third objective, we conducted two web-based surveys with  medical students who have either accepted the scholarship or are  attending the University to obtain information on the students’ perceptions  on their willingness to accept different lengths of service obligations,  among other topics. We selected scholarship program and University  participants from a stratified random sample of medical students in their  first, second, or third year of school, by military department. Our  unweighted survey response rate was 60.5 percent for scholarship  program participants and 80 percent from University students, with 624  and 259 respondents, respectively. Based on this, we determined that the  data collected from the surveys are generalizable. We developed  sampling weights per stratum and adjusted for any potential bias. All  survey estimates, including margin of errors, presented in this report  reflect the sample design and use the adjusted sampling weights.

We also conducted eight focus group meetings at three military treatment  facilities—two each with Army, Navy, and Air Force medical residents and  two cross-departmental pilot focus groups—with military medical  residents who had previously either accepted the scholarship or attended  the University. We conducted these focus groups to obtain participants’  perspectives on issues related to (1) the nature of active-duty service  obligations, including their willingness to accept different lengths of active- duty service obligations; (2) the relative importance of the service  obligations in relation to other factors at different decision points,  including accepting the scholarship or attending the University; (3)  participating in a military residency program; and (4) choosing a medical  specialty to pursue. To identify focus group participants, we considered  gender, number of residents who had accepted the scholarship or  attended the University, medical specialties, military department  affiliation, number of years in a military residency training program, and  prior service as a General Medical Officer. The focus groups involved a  range of seven to 15 participants during each meeting. We did not select  focus group participants using a statistically representative sampling  method, and therefore the information collected from the focus groups is  not generalizable and cannot be projected across DOD, a military department, or any single military treatment facility the team visited. We  also conducted interviews with DOD officials from each of the military  departments to understand their perceptions of active-duty service  obligations and the effect of these obligations on the recruitment and  retention of military physicians and dentists. Our scope and methodology  for all of our objectives is described in further detail in appendix I.

We conducted this performance audit from September 2018 to December  2019 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.

Roles and Responsibilities for the Recruitment and Retention of Military Physicians and Dentists

The ASD(HA) serves as the principal advisor for all DOD health policies  and programs. The ASD(HA) has the authority to issue DOD  instructions, publications, and memorandums that implement policy  approved by the Secretary of Defense or the Under Secretary of Defense  for Personnel and Readiness and govern the management of DOD  medical programs. The ASD(HA) also exercises authority, direction, and  control over the President of the Uniformed Services University of the  Health Sciences. Further, the ASD(HA) sets the maximum special and  incentive pay amounts for all military physicians and dentists.

The Army, the Navy, and the Air Force have the authority to recruit, train,  and retain physicians and dentists. Currently, there is no joint DOD unit  or process dedicated to recruiting medical students and accessing  medical officers because recruiting and retention are the responsibility of  the military departments. Each military department has its own  organizational structure, responsibilities, and varying degrees of  personnel resources for accessing physicians and dentists. The  departments’ recruiting commands recruit medical and dental students  into the scholarship program. In a separate process, the University  recruits and admits a set number of medical students each year. Figure 1  shows the organizational structure of the Military Health System as it  relates to the recruitment and retention of military physicians and dentists.

Career Path of Military Physicians and Dentists

DOD has two primary sources of recruitment for military physicians: the  scholarship program and the University. DOD recruits most military  dentists through the scholarship program. Participants in DOD’s  scholarship program and the University accrue an active-duty service  obligation in return for a tuition-free medical or dental education and  certain financial benefits. Specifically, scholarship program participants  enrolled in a civilian medical or dental school receive paid tuition, books  and fees, and a monthly stipend. In some cases, participants are also  offered an accession bonus. In exchange, scholarship program  participants incur a 6- month active-duty service obligation for each 6  months of benefits received, with a 2-year minimum service obligation.  Students at the University are enrolled in the DOD-sponsored medical  school at no cost, enter active-duty service as medical students and  receive the pay and benefits of an officer at the O-1 pay grade. In  exchange, University medical students accrue a 7-year service obligation.

Career paths for medical and dental school graduates can differ. For  example, Army and Air Force medical school graduates typically become  specialized before practicing medicine, while 55 percent of Navy  physicians complete a General Medical Officer tour before becoming  specialized, according to department officials. Moreover, dental school  graduates typically practice as general dentists after completing licensure  requirements before choosing to specialize. To become specialized,  medical and dental school graduates apply to a medical or dental  residency training program, which may require or include a 1-year  internship, depending on the program or specialty. After residency, some  physicians or dentists may decide to pursue further training, known as  “fellowships,” in order to become subspecialists. For example, to become  a cardiologist, a physician must complete an internal medicine residency  followed by a cardiology fellowship. Residency training typically requires 3  to 7 years for physicians and 1 to 6 years for dentists. Fellowship  training typically is 1 or more years in length for physicians and dentists.  The required number of years depends on the specialty or subspecialty.  After residency or fellowship training—hereafter referred to collectively as  residency training—physicians and dentists become credentialed and  privileged to practice the specialty or subspecialty that they trained in, and  they are also eligible for board certification. Figure 2 portrays possible  paths to becoming a military physician or dentist.

As noted earlier, scholarship program medical and dental students incur 6  months of an active-duty service obligation for each 6 months of benefits  received, with a 2-year minimum service obligation; University medical  students accrue a 7-year service obligation. While training in a military  residency program, residents receive the pay and benefits of an officer at  the O-3 pay grade or higher, depending on prior years of service, and  earn creditable years of service toward retirement. In exchange,  participants incur an additional 6 months of an active-duty service  obligation for each 6-months of residency training, with a minimum 2-year  service obligation. However, according to DOD officials, the first year of  postgraduate training (i.e., internship or 1 year of advanced education in  general dentistry and general practice residency) does not accrue a  service obligation and is considered obligation neutral. Currently, the two  sets of obligations—the obligation for medical or dental school and the  obligation for military residency training—are served concurrently, or at  the same time, effectively resulting in the servicemember serving the  longer of the two obligations. For example, a student who accepts a 4- year scholarship, trains in a 1-year internship, and then trains in a 4-year  residency program will serve a total of 9 years. The first 5 years would be  spent in internship and residency, and the final 4 years of this service  would be spent discharging the active-duty service obligations  concurrently (see figure 3, scenario 2). Depending on career path, years  of active-duty service after completion of medical and dental school will  vary (see figure 3).

Cash Compensation for Military Physicians and Dentists

DOD’s measure of cash compensation, known as regular military  compensation, includes the sum of basic pay, basic allowance for  housing, basic allowance for subsistence, and the federal income tax  advantage that accrues from the non-taxable nature of the allowances.  For example, according to DOD, in 2017 the average married military  officer at the pay grade of O-3 received annual regular military  compensation of around $99,000. Specifically, this average officer  received around $67,000 for basic pay, $24,000 for the basic allowance  for housing, $3,000 for the basic allowance for subsistence, and a federal  income tax advantage of $5,000.

In addition to regular military compensation, physicians and dentists may  be eligible for various special and incentive pays which vary depending  upon their status as residents, their service obligations, and their  specialty. During residency training, physicians and dentists are eligible  for select medical or dental corps incentive pays. Upon completion of  residency training, they become eligible for higher rates of incentive pay  and, if they become board certified, for Board Certification Pay. After  fulfilling their active-duty service obligations from medical or dental school  and residency training, in addition to special and incentive pays already  received, physicians and dentists become eligible for a multi-year  retention bonus.

Cash Compensation for Military Physicians and Dentists Is Generally Less Than the Private Sector, but DOD Provides Substantial Deferred and Noncash Benefits

Cash compensation for active-duty military physicians and dentists was  generally less than the median compensation for private sector civilians in  calendar year 2017 for most specialties we reviewed, including at key  retention points. However, a substantial portion of the costs of DOD’s  overall compensation package is comprised of deferred and noncash  benefits provided to active-duty personnel, such as a pension in  retirement and tuition-free medical and dental education, but the extent to  which servicemembers value these benefits is difficult to determine.

Cash Compensation for Military Physicians and Dentists Was Generally Below the Median of Private Sector Civilian Compensation in Comparable Specialties in 2017

Cash compensation for active-duty military physicians and dentists varied  depending on pay grade, specialty, and decisions to accept retention  bonuses or other special and incentive pays, but was generally less than  the median compensation for private sector civilians in calendar year  2017 for most specialties. Although we could not make direct  comparisons of military and private sector civilian cash compensation by  years of service or experience, we estimated the minimum and maximum  military cash compensation for specialized active-duty physicians and  dentists in pay grades O-3 to O-6, which represented more than 99  percent of military physicians and dentists in fiscal year 2018. Specifically,  we found that  the minimum military cash compensation for all 21 physician and 5 of  6 dental specialties we reviewed was less than the civilian median for  all pay grades; and  the maximum military cash compensation for 16 of 21 physician (see  figure 4 below) and 5 of 6 dental specialties (see figure 5 below) we  reviewed was also less than the civilian median for all pay grades.

Therefore, for many of these specialties, even the most senior military  physician and dentists (i.e., pay grade O-5 or higher) at the top of the pay  range were estimated to receive cash compensation below the private  sector civilian median. The minimum and maximum of total military cash  compensation, by specialty and pay grade, and how these compare to  reported private sector civilian cash compensation are presented in  appendix II.

Cash Compensation for Military Physicians and Dentists Is Generally Less Than Private Sector Civilian Compensation at Key Retention Points

Cash compensation for military physicians and dentists is generally less  than private sector civilian compensation at key retention points.  Specifically, we calculated 2017 cash compensation for military medical  officers who completed their residency directly after medical school  across 21 medical specialties and found that at their first unobligated year  of service—after they fulfill their initial active-duty service obligations  accrued from medical school and military residency training—all 21  specialties had cash compensation below the private sector civilian  median. In addition, we found that all but one specialty (psychiatry) was  less than the 20th percentile for private sector civilian compensation.  Notably, nine specialties that DOD identified as critical trauma-related  wartime specialties in 2019 were less than the 20th percentile.  According to senior military department medical corps officials, the first  unobligated year of service is a key point of retention for military  physicians. A 2012 study of military physicians found that compensation  had a large impact on the decision to remain in the military in the first  unobligated year of service and just a small impact on retention in the  years afterward. For DOD’s scholarship program participants, which  constitute the majority of recruited military physicians, we estimate that  initial service obligation fulfillment typically occurs about 4 years after  successful completion of their residency, or at about 9 years of service.

We also calculated cash compensation for military medical officers who  (a) completed a 3-year General Medical Officer tour prior to specializing  in a residency, or (b) attended the University and accrued a 7-year active- duty service obligation and found that all but three specialties (pediatrics,  family medicine, and psychiatry) had cash compensation less than the  20th percentile for private sector civilian compensation, and all specialties  were compensated below the median.

We reviewed 2017 cash compensation for typical military dental officers  across six dental specialties and found that at each of these retention  points, military cash compensation was less than the median private  sector civilian compensation, three of which were below the 25th  percentile (orthodontics, endodontics, and periodontics). According to  senior military department dental corps officials, two key points of  retention for military dentists are (1) after they fulfill their scholarship  service obligation by practicing as a general dentist for several years, and  (2) after they have completed residency training for a dental specialty,  such as orthodontics, and fulfill their residency service obligation. Unlike  their physician counterparts, dental students typically do not begin  residency immediately after graduation. According to military department  dental corps Chiefs, dental student graduates generally complete a 1- year advanced education in general dentistry certificate, which does not  incur a service obligation, then fulfill their dental school active-duty  service obligation as general dentists before taking a general dentist’s  retention bonus and beginning residency training.

Cash compensation is just one factor that servicemembers may consider  when making the decision to stay with or separate from the military.  According to DOD medical and dental corps officials, other factors that  may influence this decision include number and frequency of  deployments, ability to function at full scope of practice for training,  additional nonphysician duties and administrative requirements placed on  active-duty physicians that their private sector counterparts do not  experience, family considerations associated with permanent change of  station orders, nonselection to residency of choice, nonselection for  promotion, and retirement eligibility. Similarly, data from the 2017 DOD  Status of Forces Survey show that among all officers, the most important  factors that would be considered in a decision of whether to stay on  active-duty were the military retirement system and personal  choice/freedoms (e.g. control of where to work), as well as factors such  as opportunities to be assigned to station of choice, family concerns, and  pay and allowances. Moreover, a 2019 study of Army physician service  obligations showed that military physicians who were most likely to  continue serving after completion of their obligation and ultimately retire  were those who had the most years of service accumulated when  obligations were completed. That is, those who were close to retirement  after completing their service obligations were more likely to stay to  receive their retirement benefit.

DOD Provides Substantial Deferred, Noncash, and Other Benefits Which Must Be Considered Alongside Cash Compensation, but Value to Servicemembers Is Difficult to Quantify

In addition to cash compensation, DOD offers substantial deferred  benefits, such as retirement pensions and benefits, and noncash benefits,  such as tuition-free medical school education and health care, to its  military physicians and dentists. In its report on military compensation,  DOD noted that nearly half of military compensation is made up of  deferred and noncash benefits, and that this proportion is considerably  higher than in civilian compensation. Additionally, in 2011 we identified  military personnel costs as an area where DOD could recognize long- term cost avoidance by using a total compensation approach to manage  military compensation in a holistic manner that considers deferred and  noncash benefits alongside cash compensation.

Studies of military compensation highlight that assigning a value to  deferred and noncash benefits and comparing them to the civilian private  sector proves more difficult than for cash compensation because  servicemembers value or use these benefits differently, various  assumptions have to be made to assign value, and access to such  benefits is not universal among private sector civilian workers.  Additionally, it is difficult to measure the extent to which servicemembers  discount the value of future benefits. We previously reported that it is  generally accepted that some deferred benefits, such as a pension in  retirement, are not valued as highly by servicemembers as current cash compensation. However, a recent study found that servicemembers,  particularly military officers, may value deferred benefits more highly than  was previously reported. For these reasons we did not compare the  value of military deferred and noncash benefits to similar benefits in the  civilian private sector; however, we describe certain types of deferred and  noncash benefits available to physicians and dentists and provide  estimates of their value where possible.

DOD provides access to two primary types of deferred benefits: its  employer-sponsored retirement plans and retiree health and dental care.  As mentioned previously, the likelihood of benefiting from DOD’s military  retirement system is a factor that officers consider when deciding to stay  on active duty.

Retirement plans. In DOD’s traditional retirement system, known as the  “High-Three System,” servicemembers are eligible to receive a defined  benefit annuity based on their pay grade and years of service after a  minimum 20 years of active-duty service, with no benefits provided to  those who separate before then. This system was closed to new entrants  at the end of 2017. Based on our estimates, under the High-Three  System, the defined benefit for a physician or dentist who retires with 20  years of service in 2035 was estimated to be $2,457,253 (present  value).

New servicemembers from 2018 onwards were enrolled in the Blended  Retirement System (BRS). BRS is a hybrid retirement system that  includes a revised defined benefit plan requiring 20 years of active-duty  service, a defined contribution plan with agency matching contributions,  and a one-time direct cash payout—called continuation pay—distributed  at the midcareer point (between 8-12 years of service). Based on our  estimates, under the BRS, the defined benefit for a physician or dentist  who retires with 20 years of service in 2035 was estimated to be  $1,965,802 (present value). The defined contribution plan offers  government automatic and matching contributions of up to 5 percent of  basic pay to the servicemember’s Thrift Savings Plan, and vested  servicemembers who separate before 20 years of active-duty service  retain ownership of these contributions.

The BRS was implemented in 2018 to modernize the military retirement  system. As the Military Compensation and Retirement Modernization  Commission reported in 2015, roughly 51 percent of military officers  exited service before 20 years, meaning that most left without any  retirement benefits under the High-Three System. The BRS is expected  to provide retirement benefits for the majority of servicemembers,  including those who serve fewer than 20 years, according to DOD.

In our interviews, some DOD officials expressed concern about the  effects of BRS on retention of military physicians and dentists, because,  for example, they believed the opportunity to separate with defined  contributions will reduce their incentive to remain for a longer period of  active duty. Other DOD officials we interviewed stated that it is too soon  to determine the effects of the BRS on retention, and noted that the  inclusion of continuation pay as part of the BRS was designed to  encourage servicemembers to continue serving at the mid-career point.

Retiree health and dental care. Servicemembers retiring from active  duty are eligible to enroll in TRICARE. Specifically, retired  servicemembers and their eligible dependents are able to participate in  TRICARE Prime which is comparable to a health maintenance  organization (HMO) program, and TRICARE Select, which is comparable  to a preferred provider organization (PPO) program. After they are eligible  for Medicare, retired servicemembers and their eligible dependents with  Medicare Part A and B can enroll in TRICARE for Life, which provides  Medicare-wraparound coverage. Eligible retired servicemembers may  also receive benefits from the Department of Veterans Affairs health care  system. Specifically, active-duty servicemembers who served 24  continuous months or the full period for which they were called to active  duty are eligible for Veteran Affairs’ health care.

DOD provides access to a wide variety of noncash benefits, some of  which are uncommon in the civilian sector, and may offset some of the  discrepancies in military and private sector civilian cash compensation.  However, limited information exists on the extent to which noncash  benefits are used by military physician and dentists. Therefore, we have  highlighted select benefits that may be used by military physicians and  dentists.

Tuition-free medical and dental school. Military physicians and dentists  benefit from DOD’s scholarship program and the University, through  which prospective medical and dental students receive tuition-free  education in exchange for commitment to a number of years in active- duty service. This benefit allows physicians and dentists to avoid  thousands of dollars of student debt. For example, according to the  Association of American Medical Colleges, the average first-year medical  student paid $36,755 for tuition, fees, and health insurance to attend a  public medical school during the 2018-19 academic year, and the  average first-year student attending a private medical school paid  $59,076.

Medical and dental care. DOD offers comprehensive health coverage to  military personnel and their dependents through TRICARE, a managed  care program. Care is provided in more than 650 military treatment  facilities worldwide, supplemented by civilian providers. TRICARE offers  two health care options to non-Medicare-eligible beneficiaries: TRICARE  Prime and TRICARE Select. All active-duty servicemembers are  automatically enrolled in TRICARE Prime, which is comparable to a  private health maintenance organization plan. Under this program, active- duty servicemembers have no premium costs, deductibles, or out-of- pocket costs for servicemembers and no or low costs for dependents.  Medical Expenditure Panel Survey data indicate that the average private  sector civilian employee spent over $5,000 in health insurance employee  contributions for family coverage in 2018.

The TRICARE Active Duty Dental Program supplements the dental  services available to active-duty servicemembers at military treatment  facilities when necessary care is not available or the servicemember does  not have ready access to a military treatment facility. Active-duty  servicemembers do not pay premiums for this dental care, do not share in  the costs of the care, and do not face any annual or lifetime maximums  on the cost of care.

Financial benefits during education and training. Medical and dental  scholarship students receive O-1 pay and allowances for 45 days of  active duty for annual training performed for each year the scholarship is  awarded. Participants may also be eligible for a $20,000 signing bonus.

During their education, medical and dental scholarship students receive a  monthly stipend, and medical students at the University receive officer  salary and benefits at grade O-1. After medical school, medical and  dental residents receive officer pay and benefits at grade O-3 or higher,  according to DOD officials.

DOD Uses Incentives to Recruit and Retain Military Physicians and Dentists, but Does Not Consistently Collect Information to Help Inform Investment Decisions

Based on our analysis of DOD’s incentives to recruit and retain military  physicians and dentists, DOD generally (1) clearly defined the criteria  used to determine when to offer incentives, (2) identified and incorporated  opportunities for improvement, (3) identified and evaluated unique staffing  situations, and (4) made investments to attract and retain top talent.  However, we found that DOD did not consistently collect information on  (1) replacement costs, (2) current and historical retention efforts, and (3)  comparable civilian wages to help inform investment decisions in its  package of incentives to recruit and retain military physicians and  dentists. Fully applying these seven key principles of effective human  capital management in its approach to recruit and retain military  physicians and dentists is important to making fully informed investment  decisions.

DOD Generally Applied Four Key Principles of Effective Human Capital Management to Its Package of Incentives for Recruiting and Retaining Military Physicians and Dentists

We found that DOD generally applied effective human capital  management principles related to clearly defined criteria on when to use  incentives, making investments based on expected improvement in  agency results, identifying and evaluating unique staffing situations, and  identifying and incorporating opportunities for improvement. To support its  operational needs, DOD uses educational, training, and monetary  incentives to recruit and retain physicians and dentists. Specifically,  DOD’s package of incentives includes, among other things, a tuition-free  medical school education through the scholarship program and the  University, pay as an O-3 officer or higher during medical or dental  residency, the opportunity for further training via a fellowship, and a series  of special and incentive pays for fully trained physicians and dentists.  According to DOD’s report on military compensation, special and  incentive pay authorities provide the services with greater flexibility to  target additional compensation where needed to address emerging  staffing shortfalls and maintain staffing in critical or hard-to-fill skills.

We found that DOD generally applied four of the seven key principles, as  described below:

Relied on clearly defined, well-documented, consistently applied,  and transparent criteria. DOD and the military departments have  established rules-based pay plans with clear eligibility criteria for  special and incentive pays and recruitment and retention bonuses.  Key principles for human capital management state that agencies  should consider making targeted investments in specific human  capital approaches, and that these approaches should have clearly  defined, well-documented, transparent, and consistently applied  criteria for making these investments.

Identified opportunities for improvement and incorporated these  opportunities into the next planning cycle. The services and  officials from the Office of the ASD(HA) participate in the Health  Professions Incentives Working Group to review recruitment and  retention special pay and incentives and recommend adjustment to  amounts offered as necessary. For example, as a result of working  group discussions, DOD officials stated that they established a new 6- year retention bonus in the fiscal year 2019 pay plan for select  medical and dental specialties, in part to ensure greater stability in the  numbers of physicians and dentists within these specialties. Military  department officials stated they plan to identify potential impacts and  determine adjustments, if any, that need to be made. DOD’s report on  military compensation advises officials to identify opportunities for  improvement using analytical tools to model how changes in  compensation might alter the force or career profile. It further states  that taking a structured approach to determining both incentive pay  eligibility criteria and amounts helps force managers optimize their  limited special and incentive pay budgets. Such an approach also  provides a mechanism to periodically conduct a rigorous assessment  of such pays to ensure that they keep pace with changing conditions.

Identified and evaluated unique staffing issues. According to  military department officials, medical corps and dental corps  community managers, specialty leaders, consultants, and others  actively discuss military physicians’ and dentists’ career plans to help  inform future staffing needs. Moreover, to attract physicians and  dentists in specialties which DOD has identified as a critically short  wartime specialty, DOD offers a Critical Wartime Skills Accession  Bonus. However, as we reported in 2018, military department officials  cited a number of challenges that make it difficult to attract and retain  military physicians and dentists, including national shortages and  competition with the private sector. Incentive pay and retention  bonus amounts are specific to each specialty. DOD’s report on  military compensation states that evaluation of unique staffing issues  identified by community managers should be a core part of a  systematic approach to assessing the application of a special or  incentive pay. Similarly, key principles for human capital management  note that agencies should tailor human capital strategies to meet their  specific mission needs.

Targeted investments to attract and retain top talent. The services  are authorized to offer targeted monetary incentives in the form of  special and incentive pays and recruitment and retention bonuses to  eligible physicians and dentists who are in good standing. Moreover,  military department officials stated that DOD offers Board Certification  Pay to physicians and dentists who achieve and maintain this  accreditation because it reflects that the physician or dentist is  maintaining skills and qualifications and allows the department to  better reflect the high level of the quality of care that is provided by the  military health system. Similarly, we reported in 2018 that DOD and  the military departments had established a set of minimum  qualifications for medical school applicants applying to the scholarship  program and the University. Key principles for human capital  management state that targeted investments in human capital  approaches should help the agency attract, develop, retain, and  deploy the best talent and then elicit the best performance for mission  accomplishment. The principles further state that decisions  regarding these investments should be based largely on the expected  improvement in agency results. Similarly, DOD’s Diversity and  Inclusion Strategic Plan 2012-2017 notes that retaining top talent is  essential to sustaining mission readiness that is adaptable and  responsive.

DOD Does Not Consistently Collect Information to Help Inform Investment Decisions in Its Package of Recruitment and Retention Incentives

In three key areas of effective human capital management related to data  on replacement costs, recruitment and retention, and civilian wages, DOD  does not consistently collect information to help inform investment  decisions in its package of incentives to recruit and retain military  physicians and dentists, as described below:

Did not identify replacement costs. Military departments do not  consistently collect information on replacement costs of military  physicians and dentists. Specifically, no military department was able  to provide us with a comprehensive assessment of the replacement  cost for military physicians and dentists. Replacement cost  assessments can be found in other occupations within DOD. For  example, in 2017, we reported that the Navy considers the high  replacement costs of its nuclear propulsion personnel—up to  $986,000 per trainee—in justifying a strategy that prioritizes  investment in retention initiatives over new accessions or recruits.  Moreover, DOD requires that the training investment and replacement  cost for those qualified in the skill be considered when justifying the  need for the critical skills retention bonus. DOD’s report on military  compensation identified replacement costs and training costs as a  factor in assessing incentive pay appropriateness.

In 2018, we recommended that the ASD(HA) require that the  University develop a reliable method to accurately determine the cost  to educate its medical students. DOD partially concurred with our  recommendation. In response to our recommendation, the University  contracted with the Institute for Defense Analyses to determine the  costs to educate University medical students. In its October 2019 final  draft report, the Institute for Defense Analyses estimated total  accession costs for a fully trained physicians through both the  scholarship program and the University; specifically, the report  estimated the total cost for a fully trained physician who completes 4  years of medical school and a 3-year military residency to be  $878,000 for scholarship medical students and approximately $1.5  million for University medical students. In another similar ongoing  effort, Navy officials stated that they have commissioned a Life Cycle  Cost study with the Center for Naval Analyses. We are encouraged by  these initiatives, which will provide the Office of the ASD(HA) and the  military departments a foundation for formalizing the process of  collecting information on replacement costs. With the benefit of this  information, DOD can make more informed decisions regarding its  packages of recruitment and retention incentives.

Did not collect current and historical retention information.

Military departments do not consistently collect and use current and  historical retention information to help inform decisions about  investment in retention incentives. Specifically, Navy and Air Force  officials told us that they do not have readily available information to  determine the percentage of those who accepted a retention bonus  among the eligible population, and Army officials noted they do not  have a framework in place to use retention information to determine  the effectiveness of retention bonuses.

Using retention data to measure effectiveness of retention incentives  is performed by other communities within DOD. For example, in 2018  we reported that officials from the Navy, Marine Corps, and Air Force  measured the effectiveness of aviation retention bonuses by  monitoring bonus acceptance rates. DOD’s report on military  compensation stated that a review of current and historical data on  retention should be a core part of a systematic approach to assessing  the application of a special or incentive pay. Further, key principles for  human capital management note that periodic measurement of an  agency’s progress toward human capital goals and the extent that  human capital activities contributed to achieving programmatic goals  provides information for effective oversight by identifying performance  shortfalls and appropriate corrective actions. Without information on  the acceptance rate among those eligible, the military departments  cannot assess the effectiveness of the performance of their  investment in retention bonuses.

Did not assess private sector civilian wages. DOD does not  consistently collect and use private sector wage information to help  inform investment decisions in its special and incentive pays for  physicians and dentists. Based on our review of the minutes of  meetings of the Health Professions Incentives Working Group, which  recommends changes to the rate and term of special and incentive  pays, private sector compensation was occasionally raised as a  challenge. However, it was not collected and used to help inform  investment decisions on a consistent basis. According to officials from  the Office of the ASD(HA) and the military departments, an  assessment of civilian wages is not a driving factor when considering  adjustments to special and incentive pays, in part because DOD  cannot always match civilian sector compensation for military  physicians and dentists.

Officials from the Office of the ASD(HA) and the military departments  acknowledged the disparity between military and civilian cash  compensation varies by specialty; however, incentive pay and  retention bonus amounts have largely remained the same for over a  decade. DOD’s Ninth Quadrennial Review of Military Compensation  states that pay at around the 70th percentile of comparably educated  civilians is necessary to enable the military to recruit and retain the  quantity and quality of personnel it requires. Based on our  comparison of military and civilian cash compensation pay previously  discussed, we found that the gap between military and private sector  civilian varies by specialty and many fall below the civilian private  sector median. Moreover, based on our review of cash compensation  for medical officers who completed their residency directly after  medical school across 21 medical specialties, we found that at their  first unobligated year of service, all 21 specialties had cash  compensation below the private sector civilian median. Additionally,  all but one specialty (psychiatry) were compensated at less than the  20th percentile of private sector civilian compensation.

Use of assessments of private sector civilian compensation can be  found in other communities within DOD. For example, in 2017, we  reported that the Navy justified its use of selective reenlistment  bonuses for cyber-related occupations by noting the specific level of  starting salaries for comparable civilians. DOD’s report on military  compensation states that reviewing civilian wages is a key element in  assessing the application of a special or incentive pay. Further, it  states that periodic reviews, which should include the use of an  analytical tool or model, will ensure that resources are directed at the  most pressing staffing needs. For example, professions that  consistently command higher pay in the civilian sector—such as the  medical professions—may merit predictable pays over the long term.  Yet in other areas, evolving mission needs, changing conditions in the  civilian market, and other factors may call for increasing an incentive  or, in some cases, may show that additional pay can be reduced or  eliminated.

According to a former Under Secretary of Defense for Personnel and  Readiness and a noted expert on defense personnel issues, DOD  would benefit from analysis to determine the point at which cash  compensation for military physicians, including special and incentive  pays, reaches a minimum threshold of attractiveness compared to the  private sector. Assessing civilian wages could help DOD understand  the relationship of any military and civilian pay discrepancies to its  ability to fill particular specialties. For example, we found that in fiscal  year 2018, all but three of the specialties we reviewed were below 90  percent of authorization by at least one of the services’ active  components. By consistently collecting civilian wage information and  using it to inform its package of incentives, DOD will be better  positioned to make the most effective use of its recruitment and  retention incentives.

DOD officials stated that their approach to managing the package of  incentives to recruit and retain military physicians and dentists is driven  by a number of considerations. Specifically, DOD officials stated that the  rates of special and incentive pays represent amounts that are affordable  and that the military departments generally believe have allowed them to  meet their personnel needs. Further, military department officials stated  that budget considerations and statutory limitations hinder their ability to  change the rate of special and incentive pays. Current statutory limits to  the amount of the retention bonus, incentive pay, and board certification  pay are $75,000, $100,000, and $6,000, respectively; there is currently no  statutory limit on the critical skills retention bonus for health professionals,  which can be paid in addition to other pays. While we believe these are  valid considerations, collecting information on replacement costs,  retention, and civilian wages would allow the Office of the ASD(HA) and  the military departments to provide greater stewardship of available  funding by ensuring its efficient application. Specifically, Standards for  Internal Control in the Federal Government state that management  should use quality information to achieve the entity’s objectives. For  example, further analysis of replacement costs could reveal that retention  of fully trained physicians is highly economical for DOD, and provide  strong support for changes to retention incentives to safeguard significant  investment in physicians and dentists. By collecting and using this  information to inform its decision-making, DOD and the military  departments would be better positioned to assess the effectiveness of  their incentives to recruit and retain military physicians and dentists and  make sound investment decisions for the future.

Medical Students and Residents Perceive That Lengthening Service Obligations Could Negatively Affect Recruitment and Retention of Military Physicians

Our surveys of medical students, focus groups with medical residents,  and interviews with DOD officials showed there was a general perception  that lengthening active-duty service obligations, such as through a system  of serving obligations from medical school and residency training  consecutively, could negatively affect recruitment and retention of military  physicians. Moreover, DOD is considering reductions to the overall  number of active-duty physicians, including targeted reductions to certain  specialties, and participants in all eight focus groups with residents had  concerns about the proposed reductions to authorizations for certain  medical specialties.

Medical Students and Residents Reported General Unwillingness to Accept Longer Service Obligations without Additional Cash Incentives

In our surveys of medical students, we found that they generally would  not have accepted the scholarship or attended the University if the  service obligations from medical education and residency training were  served consecutively. Specifically, an estimated 61 percent of scholarship  recipients and an estimated 51 percent of University students in our  representative survey responded that they would not have accepted  DOD’s scholarship program or attended its University had they been  required to fulfill these service obligations consecutively. However, our  survey results indicated that students are willing to accept some  additional active-duty service obligation for their current programs.  Specifically, 68 percent of the University students and almost half (46  percent) of the scholarship students would be willing to accept an  additional year of active-duty service obligation. Notably, a lower  percentage of medical students would accept 2 additional years of active- duty service obligations—specifically 34 percent of University students  and 16 percent of scholarship recipients.

Our survey results found that medical students would be more willing to  accept longer service obligations if accompanied by additional cash  incentives. For example, 80 percent of University students and more than  half of scholarship recipients (63 percent) would be willing to accept an  additional year of service obligation if accompanied by additional cash  incentives. (See figure 6 and appendix III for specific estimates and  confidence intervals.)

Similar to the survey responses, participants in all eight focus groups with  medical residents also would not have accepted the scholarship or  attended the University under a system of consecutive active-duty service  obligations. However, participants in seven out of eight focus groups we  conducted stated that they would be more willing to accept longer service  obligations if accompanied by additional cash incentives, such as a larger  accession bonus.

Lengthening service obligations may also have unintended consequences  without other changes to DOD policy. Specifically, participants in five out  of eight of our focus groups with medical residents and DOD officials we  interviewed expressed concern that lengthening service obligations would  delay physicians’ eligibility for retention bonuses, resulting in a reduction  of cash compensation over the course of a career. For example, under  current policy, a physician who accepted a 4-year scholarship, completed  a 1-year internship, and then trained in a 4-year residency training  program would be eligible for a retention bonus after 9 years of service.  Under a consecutive service obligation model, that same physician would  be eligible for a retention bonus after 13 years of service (see figure 7).  Further, as previously reported, cash compensation for military physicians  is generally less than private sector civilian compensation, and  participants in seven out of eight of our focus groups with residents  expressed that lengthening service obligations would extend the amount  of time they would not be paid comparably to their private sector civilian  counterparts.

Residents Stated That Longer Service Obligations and Reductions in Authorizations for Medical Specialties Would Likely Affect Their Decision to Continue Military Service

Residents in our focus groups stated that lengthening active-duty service  obligations would make residency training in a military hospital less  attractive and would likely affect their decision to continue military service.  Specifically, medical residents in most focus groups we held noted that  lengthening service obligations would make them more likely to:  fulfill their medical school active-duty service obligation by serving one  or more tours as a General Medical Officer and then separate from  the military in order to train in a civilian residency program; decline to participate in further medical training and specialization via  a fellowship program within the military; and  separate from the military sooner than planned, in part because a  longer active-duty service obligation would delay their eligibility for  certain special and incentive pays.

Military department officials we interviewed expressed concern that  lengthening active-duty service obligations, such as through a system of  serving obligations consecutively, could encourage potential medical  residents to choose shorter residency training programs over longer ones.  However, participants in all eight focus groups we held with medical  residents stated that the ability to train in a chosen medical specialty is  more important than the length of the residency program, and a longer  active-duty service obligation would not influence their chosen medical  specialty.

Further, residents who participated in our focus groups stated that the  proposed reductions in authorizations—that is, funded positions—for  certain medical specialties and associated reductions in residency  program spots could negatively affect the attractiveness of residency  training in a military setting. DOD has reduced authorizations for certain  specialties based on our analysis of DOD’s Health Manpower Personnel  Data System information and is considering additional reductions to the  overall number of active-duty physicians as part of its budgeting process  for fiscal years 2020-2024, including targeted reductions to certain  specialties. For example, DOD reduced authorizations for the general  pediatrics specialty by 40 percent from fiscal year 2015 through fiscal  year 2018, and based on our surveys of medical students, 12 percent of  scholarship recipients and 16 percent of University students in the clinical  stage of medical school responded that they are interested in practicing  the pediatrics specialty after they have completed all required training.

Participants in all eight of our focus groups with residents commented that  the ability to specialize in their medical specialty of choice was important  when deciding to accept the scholarship or attend the University, and  narrowing such opportunities would negatively affect the attractiveness of  either program for future prospective participants. When reflecting on the  proposal to reduce the range of available specialties, residents  questioned their ongoing ability to practice their preferred specialty as an  active-duty servicemember. In our focus groups, some residents  expressed that this issue could play a role in their future decision to  continue military service or separate and pursue civilian medical practice.

DOD’s ability to recruit and retain the right numbers and types of  physicians and dentists depends in part on the effectiveness of the  package of incentives in which the department invests. To initially recruit  these physicians and dentists, DOD relies on its scholarship program and  University, which come with active-duty service obligations. Changes to  the structure of its active-duty service obligations could affect recruitment  and retention of physicians and dentists.

Given that DOD spends millions of dollars annually to train medical and  dental students to become fully trained physicians and dentists and that  almost half of DOD’s special pay budget is dedicated to retaining them,  consistently collecting information to help inform investment decisions is  critical to ensuring the efficiency of these significant resources. For  example, information on the replacement costs of physicians and dentists  would help DOD make decisions about whether it is more cost effective to  train or retain these personnel. Further, consistent collection of  information on the extent to which eligible physicians and dentists accept  retention bonuses will help DOD monitor the effectiveness of an incentive  that represents a significant investment by DOD. Our comparison of  military to private sector cash compensation highlighted that military  physicians and dentists generally receive less cash compensation than  their private sector civilian counterparts for most specialties we reviewed.  This differential, according to DOD officials, is one factor that  servicemembers consider in deciding whether to continue service in the  military. However, while DOD and military department officials stated that  they are aware of how prevailing private sector civilian wages for medical  and dental specialties compare to military cash compensation, they do  not consistently collect information on this matter and that its role in  setting military cash compensation is limited. By collecting and using such  information to inform investment decisions, DOD will have better  information to efficiently and effectively meet its mission of providing  health care during times of war and peace.

We are making the following three recommendations to DOD:  The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the military departments,  collect consistent information on the replacement costs of military  physicians and dentists and use this information to inform investment  decisions in the package of incentives to recruit and retain military  physicians and dentists. (Recommendation 1)

The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the military departments,  collect consistent information on current and historical retention data, to  include data on the percentage of eligible physicians and dentists who  accept retention bonuses, and use this information to inform investment  decisions in the package of incentives to retain military physicians and  dentists. (Recommendation 2)

The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the military departments,  collect consistent information on private sector civilian wages and use this  information to help inform investment decisions in the package of  incentives to recruit and retain military physicians and dentists.  (Recommendation 3)

We provided a draft of this report to DOD for review and comment. DOD  concurred with all three recommendations and noted that it will take  actions to incorporate them into policy within the next two years. DOD’s  comments are reprinted in appendix IV.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Office of the Assistant  Secretary of Health Affairs, the Secretaries of the Army, the Navy, the Air  Force, and the President of the Uniformed Services University of the  Health Sciences. 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

This report addresses the following objectives:   1.  how compensation for military physicians and dentists compares to  private sector civilians with comparable skills in 2017;   2.  the extent to which the Department of Defense (DOD) has developed  an approach to recruit and retain military physicians and dentists  through a package of incentives that reflect key principles of effective  human capital management; and   3.  the perceptions of military medical students, residents, and DOD  officials regarding active-duty service obligations, including their effect  on recruitment and retention.

Objective 1 - Comparison of Compensation

For our first objective, we compared cash compensation for military  physicians and dentists to comparable private sector civilian specialties,  described the deferred and noncash benefits available to military  physicians and dentists, and created estimates of the value of DOD’s  retirement benefit for officers with varying current years of service.

To compare cash compensation for military physicians and dentists to  comparable private sector civilian specialties, we estimated military cash  compensation and compared that to civilian compensation data reported  in surveys by the American Medical Group Association and American  Dental Association.

Specialty selection. To select DOD physician and dental specialties that  have private sector civilian equivalents, we began with the list of 44  physician and 11 dental specialties in DOD’s Fiscal Year 2018 Health  Manpower Personnel Data System report. We selected 21 physician  specialties in consideration of the following factors: a comparable private  sector civilian specialty existed; the majority of the physician workforce  was represented; deploying specialties were included; a balance of  procedural, surgical, and other specialties was included, and; specialties  identified as critically-short, trauma-related wartime specialties were  included. We selected six dental specialties in consideration of the  following factors: a comparable private sector civilian specialty existed,  and private sector civilian compensation information was available.

Estimates of military cash compensation. To estimate cash  compensation for military physicians and dentists for our selected  specialties, we reviewed DOD policy and guidance and relevant statutes  to identify any current measures of cash compensation and other key  elements of cash compensation for physicians and dentists. DOD’s  measure of cash compensation, known as regular military compensation,  includes the sum of basic pay, average basic allowance for housing,  basic allowance for subsistence, and the federal income tax advantage  that accrues from the nontaxable nature of the allowances. Another key  element of cash compensation is the special and incentive pays that DOD  offers to eligible military physicians and dentists, such as incentive pay,  Board Certification Pay, and retention bonuses. We collected information  on basic pay, basic allowance for housing, and basic allowance for  subsistence for married personnel from DOD’s fiscal year 2017  Greenbook publication, and information on incentive pays, Board  Certification Pay, and retention bonuses from DOD’s fiscal year 2017  Health Professions Officer Special and Incentive Pay Plan. We selected  fiscal year 2017 because it was the most recent year of available data  amongst all of our sources, and we selected married personnel because  according to a DOD report, the majority of officers in the pay grades O-4  to O-6 are married, which largely aligns with DOD's population of  physicians and dentists.

We estimated a range—the minimum and maximum—of military cash  compensation by specialty for pay grades O-3 to O-6. The minimum and  maximum are based on two scenarios that represent a range of pay that  specialized physicians and dentists can expect to receive, considering  only the special and incentive pays listed in the Health Professions Officer  Special and Incentive Pay Plan. The minimum includes regular military  compensation, Board Certification Pay, and incentive pay. The maximum  includes the regular military compensation, Board Certification Pay, and  incentive pay at a higher amount in conjunction with a 4-year retention  bonus. Our estimates represent the sum of basic pay, average basic  allowance for housing, basic allowance for subsistence, special and  incentive pays, and the federal tax advantage that accrues from the  nontaxable nature of the allowances. To calculate the federal tax  advantage, we used the 2018 federal tax tables and applied the 2018  federal tax standard deduction and then converted the calculated federal  tax advantage to 2017 dollars. According to a senior DOD dental corps  official, most general dentists are not board-certified and do not receive  Board Certification Pay; we therefore omitted Board Certification Pay in  our estimates for the minimum and maximum military cash compensation  of general dentists.

Private sector civilian cash compensation information. To identify  private sector civilian cash compensation for physicians in comparable  specialties, we chose the American Medical Group Association’s 2018  Medical Group Compensation and Productivity Survey—2018 Report  Based on 2017 Data because (1) it included all the specialties we  selected to review, and (2) it contained information on physicians who  practiced in settings that were similar to those in which federal physicians  practiced.The survey data provided compensation amounts for each  specialty by 20th percentile, median, and 80th percentile. The data  excluded the value of any employer-provided malpractice insurance, but  some physicians may incur costs for this coverage. Military physicians  generally do not need to purchase malpractice insurance.

To identify private sector civilian cash compensation for dentists in  comparable specialties, we chose the American Dental Association’s  Health Policy Institute, Income, Gross Billings, and Expenses: Selected  2017 Results from the Survey of Dental Practice because (1) it included  all the specialties we selected to review, and (2) included the net income  of dentists and specialists in private practice, which is comparable to  military dentists who generally do not need to purchase malpractice  insurance. We obtained net income information for full-time  practitioners—those who reported working 35 hours a week or more— from the American Dental Association. The survey data provided  compensation amounts for each specialty by 25th percentile, median, and  75th percentile. Both surveys represent salaries for 2017.

To help determine the reliability and accuracy of private sector civilian  compensation information, we checked these data for reasonableness  and the presence of any obvious or potential errors in accuracy and  completeness. We believe the data are sufficiently reliable for the  purpose of this report.

Comparisons of military and private sector civilian cash  compensation. We compared our estimates of the ranges of military  cash compensation by specialty and pay grade to the ranges of private  sector civilian cash compensation by specialty from our selected surveys.  As we could not make direct comparisons of military and civilian cash  compensation by years of service or experience due to data limitations,  we compared and presented the ranges of compensation as appropriate.

We also compared military cash compensation at the first unobligated  year of service to the range of private sector civilian cash compensation,  by specialty. We estimated military cash compensation at the first  unobligated year of service based on the length of each residency and, if  applicable, fellowship—among other assumptions. We identified  physician residency and fellowship length information by using the  Accreditation Council for Graduate Medical Education’s Data Resource  Book for Academic Year 2017-2018, and we requested information on  military residency lengths from military department officials to confirm that  residency lengths generally aligned with this information. We identified  dentist residency and fellowship length information by requesting it from  military department officials.

For each specialty, we estimated the officers’ pay grade using the  following assumptions: (1) no creditable service before medical or dental  school; (2) a 4-year medical or dental school duration; (3) participants  were commissioned at the O-3 pay grade after medical or dental school  completion with 4 years of constructive credit—in accordance with entry  grade credit guidance outlined in DOD Instruction 6000.13; (4) the first  year of post-graduate medical or dental education does not accrue an  active-duty service obligation, and; (5) were promoted to O-4 at 6 years of  service, and to O-5 at 12 years of service—in accordance with DOD’s  promotion schedule outlined in DOD Instruction 1320.13. The entry grade  credit and promotion schedule practices were confirmed by DOD officials.

For physicians, we assumed that the active-duty service obligations for  medical school and residency were served concurrently, in other words  we assumed immediate entry into a residency program. We performed  our calculations twice, first assuming no tour as a General Medical Officer  and second assuming that physicians completed a 3-year tour as a  General Medical Officer—adding 3 years to their years of service at  service obligation fulfillment. According to Navy medical corps officials, 55  percent of Navy physicians perform such a tour. When assuming no  General Medical Officer tour, the majority of physicians reached this  decision point at the O-4 pay grade with the exception of neurosurgeons  and cardiac/thoracic surgeons, who were at the O-5 pay grade due to  longer residency and fellowship lengths. When assuming a 3-year  General Medical Officer tour, physicians in 12 specialties reached this  point at the O-5 pay grade, with the remaining nine specialties at the O-4  pay grade. We also conducted this analysis for Uniformed Services  University of the Health Sciences (University) students who accrued a 7- year active-duty service obligation. We found that assuming a 7-year  obligation for University students produced the same results as assuming  a 3-year tour as a General Medical Officer for Health Professions  Scholarship Program (scholarship) participants.

For dentists, we assumed that the dental school and residency  obligations were not served concurrently because, according to the  military department Dental Corps Chiefs, dental student graduates  typically complete a 1-year advanced education in general dentistry  certificate, which does not incur a service obligation, then fulfill their  dental school active-duty service obligation as general dentists before  taking a general dentist’s retention bonus and beginning residency  training. We completed an analysis to understand how the pay grade at  the first year of unobligated service may vary for general dentists who  worked as a general dentist immediately after completing dental school or  completed a 1-year advanced education residency. We found that  general dentists generally reached this decision point at the O-3 pay  grade; endodontists, orthodontists, pedodontists, and periodontists  reached it at the O-4 pay grade, and; oral and maxillofacial surgeons  reached it at the O-5 pay grade.

Estimates of retirement benefit. To develop estimates of the value of  the defined benefit portion for DOD’s two retirement benefit programs— the Blended Retirement System (BRS) and the High-Three—we  developed two scenarios for a hypothetical officer who either chose to  remain in the High-Three System or to opt into the BRS.  We used DOD’s  publically-available, online retirement calculators to generate an estimate  for each scenario, which Office of the Under Secretary for Personnel and  Readiness officials described as the best available tools to determine the  value of military retirement benefits.  Specifically, the estimates were for  a physician or dentist who was commissioned as an O-3 officer in 2015  and assumed separation from service at 20 years. For these scenarios,  we developed reasonable estimates to enter into the calculators. For  example, in the personal information section of the calculators we  estimated the pay entry base date assuming that the officer began  earning creditable years of service toward retirement after medical or  dental school and that they began active-duty service as an officer at the  O-3 pay grade in the month of June after the completion of medical or  dental school. The calculators produced an estimate of the present value  estimated retirement benefit at 20 years of service, which is when the  defined benefit portion becomes effective. Estimates were as of August  2019 and included a specific value for the defined benefit. DOD’s  publically available retirement calculators use a discount rate of 5 percent  per year, as of July 2018. We also consulted with a senior DOD official  from the Office of the Under Secretary for Personnel and Readiness to  corroborate the reasonableness of our approach. To help determine the  reliability and accuracy of DOD’s retirement calculators, we checked the  data for reasonableness and the presence of any obvious or potential  errors in accuracy and completeness and interviewed DOD officials  knowledgeable about the data. We believe the data are sufficiently  reliable for the purpose of this report.

Description of deferred and noncash benefits. To describe deferred  and noncash benefits available to military physicians and dentists, we  reviewed our prior reports, other relevant research, and publically  available reports and information from DOD. We interviewed cognizant  DOD officials to understand which benefits military physicians and  dentists were most likely to utilize.

Objective 2 – DOD’s Approach to Recruit and Retain Physicians and Dentists

For our second objective, we reviewed pay plans, policies, and other  documents developed by the Office of the Assistant Secretary of Defense  for Health Affairs (OASD(HA)) and the respective military departments  concerning DOD’s approach to recruitment and retention of military  physicians and dentists. We also interviewed officials from OASD(HA)  and the military departments concerning their decision-making processes  in managing this package of incentives. We compared this information  with seven key principles of effective human capital management, which  was reported in our February 2017 report on military compensation. As  we reported in that report, to identify key principles of effective human  capital management, we reviewed a compilation of our body of work on  human capital management, DOD’s Report of the Eleventh Quadrennial  Review of Military Compensation, and the DOD Diversity and Inclusion  Strategic Plan 2012 - 2017. The seven key principles of effective human  capital management include (1) criteria for making human capital  investments are clearly defined, well-documented, consistently applied,  and transparent; (2) replacement costs of personnel are considered when  deciding to invest in recruitment and retention programs; (3) decisions  regarding human capital investments are based largely on expected  improvement in agency results and implemented in a manner that fosters  top talent; (4) unique staffing issues are identified and evaluated as part  of establishing the incentive structure; (5) opportunities for improvement  are identified and incorporated into the next planning cycle; (6) current  and historical retention data are collected and reviewed as part of efforts  to evaluate effects and performance of human capital investments; and  (7) civilian wages are assessed and plans are updated as needed. In  addition to using the key principles, we also compared aspects of DOD’s  approach to recruitment and retention of military physicians and dentists  with federal internal control standards, which state management should  use quality information to achieve an entity’s objectives, and highlighted  areas where DOD’s approach differed from these principles.

Objective 3 – Perceptions Regarding Active-Duty Service Obligations

For our third objective, to obtain perceptions of (1) military medical  students, (2) residents, and (3) DOD officials regarding active-duty  service obligations, including their effect on recruitment and retention, we  utilized, respectively, (1) web-based surveys of military medical students,  (2) focus groups with military medical residents, and (3) interviews with  knowledgeable officials.

Surveys. For our third objective, to obtain perceptions of military medical  students regarding active-duty service obligations, including their effect  on recruitment and retention, we conducted two web-based surveys with  a generalizable sample of current scholarship and University medical  students to obtain information on the students’ knowledge of the current  program and willingness to accept different lengths of service obligations  or a change to a consecutive service obligation model (see table 1). One  survey was administered to current scholarship medical students, while  the other was administered to current University medical students. The  questions in both surveys were largely the same. The main differences  reflected the different pay and benefits from accepting a scholarship or  attending the University and the differences in length of active-duty  service obligation. For example, scholarship students receive a monthly  stipend and, sometimes, an accession bonus, while University students  receive the pay and allowances for commissioned officers in the O-1 pay  grade. Scholarship participants incur 6 months of an active-duty service  obligation for each 6 months of scholarship benefits they receive, with a  2-year, minimum  service obligation, while University medical students  accrue a 7-year active-duty service obligation. A full listing of survey  questions is provided in appendix III.

We worked with our social science survey specialists to develop our  survey questionnaires, applying generally accepted survey design  standards. We conducted pretests of the survey with scholarship and  University students who varied by number of years in medical school and  military service. Pretesting is necessary to ensure common understanding  of terms used and to minimize errors that might occur from respondents  interpreting the questions differently than we intended. During each  pretest, the subject was not provided the draft survey in advance, but  instead was either provided the draft survey at the meeting, or the survey  was emailed to the subject at the beginning of the teleconference. After  the pretester completed the survey, we discussed all survey questions  and response options with the pretester to ensure clarity. We revised the  survey instruments based on the feedback we received during each of the  pretests until clarity issues were reasonably addressed.

We determined fourth-year medical students were less likely to participate  in the survey for three reasons: (1) they were close to graduating from  medical school at the time the survey instrument was launched; (2) they  lose their school email addresses shortly after graduation; and (3) once  they are out of medical school, they are further removed from the decision  point about either accepting the scholarship or attending the University.  Therefore, we excluded them from the sample population. Dental  students were also excluded from the sample population because they  generally practice as general dentists after graduating from dental school  and before training in a residency program, which differs significantly from  the career paths of scholarship and University medical students.

We defined our target population to be all medical students in their first,  second, or third school year under the scholarship program or enrolled at  the University. By stratifying, as shown in table 1, the sample allowed us  to estimate any population figure across the service with a predetermined  statistical precision. We determined the target sample size needed to  achieve precision levels of plus or minus 10 percentage points or fewer,  at the 95 percent confidence level. We then increased the sample size  within each stratum for an expected response rate of 25 percent.

The resulting sample frame included 2,972 students, and we selected a  stratified random sample of 1,355. We stratified the sampling frame into  four mutually exclusive strata based on medical program and service.  One survey was administered to current scholarship medical students  from June 26, 2019 through August 26, 2019; the survey of current  University medical students was administered from June 25, 2019  through August 6, 2019.  We created two administrative email accounts,  one for scholarship medical students and one for the University medical  students, through which we sent an announcement email to the medical  students in our sample population. We administered the survey through a  web-based application and sent an email from the administrative email  accounts stating that the survey was ready to complete. When we  received bounce-back messages, we used secondary email addresses if  available or called students to request updated contact information. To  maximize our response rate, we sent two reminder emails and contacted  nonrespondents by telephone to encourage them to complete the survey.  Also, we took steps in the development of the survey, data collection, and  data analysis to minimize nonsampling errors and help ensure the  accuracy of the answers that were obtained. For example, a social- science survey specialist helped to design the questionnaire, in  collaboration with analysts having subject-matter expertise. Then, as  noted earlier, the draft questionnaire was pretested to ensure that  questions were relevant, clearly stated, and easy to comprehend.

Our unweighted survey response rate was 60.5 percent for scholarship  students and 80 percent for University students, with 624 and 259  respondents, respectively. Per Office of Management and Budget (OMB)  Standards and Guidelines for Statistical Surveys, a nonresponse bias  analysis should be conducted for a survey with a response rate less than  80 percent (Guideline 3.2.9). The response rate for the survey of  University students met this threshold, and we did not assess the  potential for nonresponse bias. With respect to scholarship students, after  conducting an analysis of propensity of responding to the survey to  identify potential sources of nonresponse bias, we identified differential  student response patterns by military department and marital status.

We developed sampling weights based on the population size, divided by  the number of sample students within each stratum. Weights were  adjusted for overall nonresponse in University students and nonresponse  by military department and marital status among scholarship students so  that statistical estimates for survey response percentages are  generalizable to the population of students.

We expressed the precision of our particular sample’s survey responses  as a 95 percent confidence interval. This is the interval that would contain  the actual population value for 95 percent of the samples we could have  drawn. As a result, we were 95 percent confident that each of the  confidence intervals in this report included the true percentages of survey  responses in the study population. All survey response percentage  estimates presented in this report from this survey had a margin of error  of plus or minus 6 percentage points or fewer, unless otherwise noted.

Focus groups. We also conducted eight focus group meetings with a  nongeneralizable sample of 79 military medical residents at three military  treatment facilities to obtain the perspectives of military medical residents  on issues related to: (1) the nature of active-duty service obligations,  including their willingness to accept different lengths of active-duty service  obligations; (2) the relative importance of the service obligations in  relation to other factors at different decision points, including accepting  the scholarship or attending the University; (3) participating in a military  residency program, and; (4) choosing a medical specialty to pursue.  These meetings involved structured small-group discussions designed to  gain more in-depth information about specific issues that cannot easily be  obtained from single or serial interviews.

Consistent with typical focus group methodologies, our design included  multiple groups with varying characteristics but some similarity in  experience and responsibility. To identify focus group participants, we  considered gender, number of residents who had accepted the  scholarship or attended the University, medical specialties, military  department affiliation, number of years in a military residency training  program, and prior service as a General Medical Officer. The focus  groups involved a range of seven to 15 participants during each meeting.  We did not select participants using a statistically-representative sampling  method, so the information collected from the focus groups is not  generalizable and, therefore, cannot be projected across DOD, a military  department, or any single military treatment facility we visited.

The eight focus group sessions included two pilot focus groups at Walter  Reed National Military Medical Center and two sessions for each of the  three military departments (Army, Navy, and Air Force). To identify the  focus group locations, we selected military treatment facilities that  included a diverse mix of medical specialties and a large pool of residents  from which to select participants in order to ensure sufficient participation  in the focus groups. We traveled to military treatment facilities in  Bethesda, Portsmouth, and San Antonio to conduct the focus groups.  Table 2 illustrates the total number of focus group participants  categorized by military treatment facility, military department, and whether  they accepted the scholarship or attended the University.

To conduct the focus groups, one of our trained facilitators moderated  each of the sessions, following a protocol that included discussion  guidelines and a set of eight questions (see table 3). The focus group  protocol was validated by one of our methodologists with a social science  background and knowledge of small group methods. The same focus  group protocol was used at all military treatment facilities the engagement  team visited, with some minor modifications made after the pilot sessions  at Walter Reed National Military Medical Center. We assured participants  that their names would not be directly linked to their responses, and that  the results would generally be reported in the aggregate. Because of the  limitations on the use of data derived from the focus group meetings,  including the nongeneralizable sample and results reported in the  aggregate, we did not rely entirely on focus groups, but rather used  several different methodologies to corroborate and support our  conclusions, including web-based surveys with medical students who  either accepted the scholarship or attended the University, and interviews  with DOD officials.

We performed a content analysis on the responses to identify common  themes from across the responses to determine their frequencies. For the  qualitative analysis, we developed a standard coding scheme to identify  common themes and determine their frequencies. We also identified  other themes that we determined to be important based on our surveys  with scholarship and University medical students and interviews with  DOD officials.

To obtain information concerning military dental residents’ views,  perceptions, and feelings on issues related to the nature of active-duty  service obligations, including their willingness to accept different lengths  of service obligations and a change from a concurrent to a consecutive  model of service obligation fulfillment, we conducted two focus group  sessions with 20 Air Force dental residents who were in training at the Air  Force Postgraduate Dental School, Joint Base San Antonio. The focus  group participants had previously accepted the scholarship and varied by  gender, rank, prior military service, dental specialty, and number of years  in dental residency training. These discussions were conducted using a  method and protocol that was similar to the approach for the medical  students.

After analyzing the results of these two focus groups with military dental  residents and taking into consideration the interviews we conducted with  DOD officials, we determined it was not necessary to conduct further  focus groups with military dental residents or include dental students in  our survey of current scholarship students. Dental students’ career paths  differ in significant ways from medical students’ career paths. According  to DOD officials and residents in the dental focus groups, military dentists  are generally already serving consecutive service obligations by fulfilling  their active-duty service obligation from dental school while serving as  general dentists before training in a military residency program. As a  result, a change from a concurrent to a consecutive service obligation  model may not affect military dentists in a similar way that it would military  physicians.

Interviews. In addition, we conducted interviews with relevant DOD  officials to understand their position on the effect of the length of active- duty service obligations on recruitment and retention of military physicians  and dentists. Specifically, we interviewed officials from the Office of the  Assistant Secretary of Defense for Health Affairs; the Office of the Under  Secretary of Defense for Personnel and Readiness; the Defense Health  Agency, and; various areas within the military departments with  responsibilities related to medical or dental corps recruitment, retention,  and education, such as the Offices of the Surgeons General, Manpower  and Reserve affairs, and medical and dental corps or commands.

We conducted this performance audit from September 2018 to December  2019 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: Cash Compensation of Specialized Military Physicians and Dentists Compared to Private Sector Civilians, 2017

Appendix II: Cash Compensation of  Specialized Military Physicians and Dentists  Compared to Private Sector Civilians, 2017 percentile) percentile)

Below 20th percentile  Below 20th percentile  median  percentile) percentile)

Radiology- Diagnostic   (Interventional)

Radiology- Diagnostic  (Non-Interventional)

The American Medical Group Compensation and Productivity Survey information represents the total  annual compensation of the physician, including base and variable compensation plus all voluntary  salary reductions. Examples of total compensation would include, but are not limited to, the following:  compensation paid as salary or production-based compensation plans, any type of additional  bonuses or incentives, clinically-related medical directorships, call coverage, and ancillary or  advanced practice clinical supervision stipends. Compensation excludes any fringe benefits and  employer payments to any type of retirement, pension, Supplemental Executive Retirement Plan, or  tax-deferred profit-sharing plan.

compensation   (25th percentile,  median, 75th  percentile) percentile)

Below 25th percentile  Below 25th percentile  below median  compensation   (25th percentile,  median, 75th  percentile) percentile)

The American Dental Association, Health Policy Institute, Survey of Dental Practice information  represents the reported annual net income of specialists in private practice, 2017. We obtained net  income information for full-time practitioners—who reported working 35 hours a week or more—from  the American Dental Association (ADA). Payments toward a retirement plan are included in net  income.

Appendix III: Estimated Population Proportion of Questions from GAO’s Surveys of Military Medical Students

We conducted two web-based surveys with a generalizable sample of  current Health Professions Scholarship Program (scholarship) and  Uniformed Services University of the Health Sciences (University)  medical students to obtain information about the students’ knowledge of  the current program and willingness to accept different lengths of service  obligations or a change to a consecutive service obligation model. One  survey was administered to current scholarship medical students from  June 26, 2019 through August 26, 2019; the survey of current University  medical students was administered from June 25, 2019 through August 6,  2019. The questions in both surveys were largely the same. The main  differences reflected the different pay and benefits from accepting a  scholarship or attending the University and the differences in length of  active-duty service obligation. The survey provided to scholarship  students also included questions about whether students considered  attending the University, while the survey provided to University students  did not include a question about whether they considered accepting the  scholarship. As a result, the scholarship survey had additional questions  than the University survey. Responses to selected questions we asked in  the surveys that were directly applicable to the research objectives in this  report are shown below. The surveys consisted of closed- and open- ended questions, including demographic questions that were used in our  analyses of the students’ responses. In this appendix, we did not provide  information on responses provided to the open-ended or the demographic  questions. See appendix I for a full description of the survey and  estimation methodologies.

The U.S. Government Accountability Office (GAO), an agency of the United  States Congress, is studying the active-duty service obligation associated  with the Armed Forces Health Professions Scholarship Program (HPSP)  and the Uniformed Services University of the Health Sciences (USUHS).

As a part of this study, GAO is conducting a nationwide survey of medical  students who are participating in the HPSP or attending USUHS. We  appreciate your insights, as it is important for GAO to provide student  views of the current program to the Congress.

Question 1 - How much did the following factors contribute to your decision to accept the HPSP scholarship?  95 Confidence  Interval – lower  bound (percentage)

95 Confidence  Interval - upper  bound (percentage)

NA  e.  Desire to provide care to military personnel, dependents, and retirees  f.  Desire to provide medical care while deployed  g.  Other (please specify below)

Generally, participants in the HPSP incur a 1-year active-duty service  obligation for each year of HPSP scholarship accepted. Similarly, a  military residency may also result in an active- duty service obligation of 1  year for each year of residency. Currently, these two sets of  obligationsare served at the same time, so a servicemember will  effectively serve the longer of the two obligations.

Residencies vary in length, and result in different service obligations. One  example would be that a service member accepts 4 years of HPSP  funding, requiring a 4-year active-duty service obligation, AND completes  a 4-year military residency, which requires a 3-year active-duty service  obligation.

A 4-year military residency only requires a 3-year active-duty service  obligation because the intern year or first year of residency does not  result in a service obligation. Under the current system, this  servicemember would serve both obligations (4 years and 3 years) at the  same time. Completion of the first 3 years would satisfy the residency  obligation and 3 of the 4 years of HPSP obligation; the final 1 year would  satisfy the remaining HPSP obligation.

Question 3 - When you decided to accept an HPSP scholarship, how familiar were you, if at all, with the active-duty service  obligation requirements for HPSP and for completing a military residency?  95 Confidence  Interval – lower  bound (percentage)

Alternative Active-Duty Service Obligations

95 Confidence  Interval – lower  bound (percentage)

95 Confidence  Interval - upper  bound (percentage)  a.  An additional 1-year service obligation for 4 years of HPSP (1.25 years of commitment for each year of funding)? (No change  in the service obligation for the medical residency.) (CHECK ONLY ONE ANSWER)

No  Don’t Know  b.  An additional 2-year service obligation for 4 years of HPSP (1.5 years of commitment for each year of funding)? (No change  in the service obligation for the medical residency.) (CHECK ONLY ONE ANSWER)

Additional service obligations and incentives  c.  An additional 1-year service obligation for 4 years of HPSP AND additional cash incentives? (No change in the service  obligation for the medical residency.) (CHECK ONLY ONE ANSWER)

28.3  95 Confidence  Interval – lower  bound (percentage)

95 Confidence  Interval - upper  bound (percentage) d.  An additional 2-year service obligation for 4 years of HPSP AND additional cash incentives? (No change in the service  obligation for the medical residency.) (CHECK ONLY ONE ANSWER)  e.  Service obligations served one after the other? For example, a service obligation for 4 years of medical school with the  HPSP scholarship and a 4 year military residency have two service obligations – 4 years for HPSP and 3 years for the  residency. Service obligations served one after the other in this example would result in a term of 7 years. (CHECK ONLY  ONE ANSWER)  f.  A 4-year active-duty commitment AND a 2-year selected reserve commitment? Currently, HPSP participants may be subject  to an individual ready reserve commitment after the completion of their active-duty service obligation. With a selected reserve  commitment, reservists typically drill about 1 weekend a month and 2 weeks a year, and may be activated in support of  military operations. (CHECK ONLY ONE ANSWER)

If ‘No’ or ‘Don’t Know’ to Questions 5a, 5b, 5c, 5d, 5e, or 5f   Which of the following funding options, if any, would you have pursued instead of accepting the HPSP scholarship? (CHECK  ALL THAT APPLY)

Personal or family resources   Yes  National Health Service Corps Scholarship Program  None - would not have attended medical school  Other (please specify)

GAO Survey of Uniformed Services University of the Health Sciences Students

The U.S. Government Accountability Office (GAO), an agency of the  United States Congress, is studying the active-duty service obligation  associated with the Armed Forces Health Professions Scholarship  Program (HPSP) and the Uniformed Services University of the Health  Sciences (USUHS).

As a part of this study, GAO is conducting a nationwide survey of medical  students who are participating in the HPSP or attending USUHS. We  appreciate your insights, as it is important for GAO to provide student  views of the current program to the Congress.

Question 1 - How much did the following factors contribute to your decision to attend USUHS?

95 Confidence  Interval – upper  bound  (percentage) a.  Desire to avoid or reduce medical school debt  b.  Officer pay while in school  c.  Desire to serve your country in the armed forces  34.1  95 Confidence  Interval – lower  bound (percentage)

Very Great Contribution  Substantial Contribution  Some Contribution  Little or No Contribution  h.  Other (please specify below)

The active-duty service obligation for completing the 4-year program at  USUHS is 7 years. A military residency also results in an active-duty  service obligation of 1 year for each year of residency, with the exception  of the first year or intern year, which does not result in an active duty  service obligation. Currently, these obligations are served at the same  time, so a servicemember will serve the longer of the two obligations.

Residencies vary in length and result in different service obligations. An  example would be that a servicemember completes medical school at  USUHS, which requires a 7-year active-duty service obligation, AND  completes a 4-year military residency, which requires a 3-year active-  duty service obligation. A 4-year military residency only requires a 3-year  active-duty service obligation because the intern year or first year of  residency does not result in a service obligation. Under the current  system, this servicemember would serve both obligations (7 years and 3  years) at the same time. Completion of the first 3 years would satisfy the  residency obligation and 3 of the 7 years of USUHS obligation; the next 4  years would satisfy the remaining USUHS obligation.

Question 2 - When you decided to attend USUHS, how familiar were you, if at all, with the active- duty service obligation  requirements for attending USUHS and for completing a military residency?  95 Confidence  Interval – lower  bound (percentage)

95 Confidence  Interval – upper  bound  (percentage)

Question 3 - When you decided to attend USUHS, how familiar were you with the fact that the medical school and military  residency service obligations are served at the same time? (CHECK ONLY ONE ANSWER)  95 Confidence  Interval – lower bound  (percentage)

95 Confidence  Interval – lower  bound (percentage)

95 Confidence  Interval – upper  bound  (percentage)  a.  An additional 1-year service obligation for attending USUHS? (No change in the service obligation for the medical residency.)  71.8  23.3  b.  An additional 2-year service obligation for attending USUHS? (No change in the service obligation for the medical residency.)

No  Don’t Know  Additional service obligations and incentives  c.  An additional 1-year service obligation for attending USUHS AND additional cash incentives? (No change in the service  obligation for the medical residency.)

NA  19.4  95 Confidence  Interval – lower  bound (percentage)

95 Confidence  Interval – upper  bound  (percentage) d.  An additional 2-year service obligation for attending USUHS AND additional cash incentives? (No change in the service  obligation for the medical residency.)

No  Don’t Know  e.  Service obligations served one after the other? For example, a service obligation of 7 years for attending USUHS and a 4- year military residency has two service obligations – 7 years for USUHS and 3 years for the residency. Service obligations  served one after the other in this example would result in a term of 10 years.  f.  A 7-year active-duty commitment FOLLOWED BY a 2-year selected reserve commitment? Currently, USUHS graduates may  be subject to an individual ready reserve commitment after the completion of their active-duty service obligation. With a  selected reserve commitment, reservists typically drill about 1 weekend a month and 2 weeks a year, and may be activated  in support of military operations. (No change in the service obligation for the medical residency)

If ‘No’ or ‘Don’t Know’ to Questions 4a, 4b, 4c, 4d, 4e, or 4f  Which of the following funding options, if any, would you have pursued instead of attending USUHS? (CHECK ALL THAT  APPLY)

National Health Service Corps Scholarship Program  19.0  95 Confidence  Interval – lower  bound (percentage)

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),  Adam Howell-Smith (Analyst in Charge), Taylor Bright, Timothy Carr,  Breanne Cave, Alexandra Gonzalez, Caitlin Jackson, Ronald La Due  Lake, Won (Danny) Lee, Kirsten Leikem, Amie Lesser, Amanda Miller,  Dae B. Park, Stephanie Santoso, and Lillian Yob made key contributions  to this report.

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.

Military Personnel: DOD Needs to Improve Dental Clinic Staffing  Models and Evaluate Recruitment and Retention Programs.  GAO-19-50. Washington, D.C.: December 13, 2018.

Military Personnel: Additional Actions Needed to Address Gaps in  Military Physician Specialties. GAO-18-77. Washington, D.C.:  February 28, 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.

Military Compensation: Additional Actions Are Needed to Better  Manage Special and Incentive Pay Programs. GAO-17-39.  Washington, D.C.: February 3, 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: Actions Needed to Help Ensure Full Compliance  and Complete Documentation for Physician Credentialing and  Privileging. GAO-12-31. Washington, D.C.: December 15, 2011.

Military Cash Incentives: DOD Should Coordinate and Monitor Its Efforts  to Achieve Cost-Effective Bonuses and Special Pays. GAO-11-631.  Washington, D.C.: June 21, 2011.

Military Personnel: Status of Accession, Retention, and End Strength  for Military Medical Officers and Preliminary Observations Regarding  Accession and Retention Challenges. GAO-09-469R. Washington,  D.C.: April 16, 2009.

DOD spends hundreds of millions of dollars annually to recruit, educate, train, and retain military physicians and dentists. Despite this, DOD has had trouble meeting its needs for certain critical specialists, in part because it pays less than the private sector. In 2017, the maximum a military physician or dentist could earn was less than the private sector median in 21 of 27 specialties we reviewed.

To help inform future decisions about the size and types of incentives to offer, we recommend that DOD collect information on the cost to replace current personnel, acceptance rates for retention bonuses, and private sector wages.