Summary
The Department of Defense (DOD) needs to apply a tri-service strategy nationwide to account for the resources its military treatment facilities in the national capital area need for both readiness and peacetime care. By also considering resources available in the local civilian community, DOD would then have a systematic basis to justify budget requests. In the 1990s, DOD and the services' surgeons general implemented DOD's managed care program, reduced the number of medical personnel, consolidated graduate medical education programs, established partnerships with the Department of Veterans Affairs, and undertook several other improvement initiatives. Recent efforts include a project to develop a tri-service strategy to account for current and projected beneficiary populations, focus on the military health system's basic wartime and peacetime care missions, and optimally seek to realign military treatment facilities' staffing and resource allocations. GAO suggests that DOD top management continue to scrutinize this project and periodically report to Congress on progress being made.
GAO noted that: (1) despite successful DOD and service efforts to improve MHS management, DOD still lacks a comprehensive tri-service strategy for determining and allocating medical resources among MTFs; (2) consequently, neither GAO nor DOD can fully address the need for, or appropriate size of NCA MTFs or MTFs elsewhere in MHS; (3) a tri-service strategy applied systemwide would enable DOD to assess the need for each MTF by taking into account the resources needed for both readiness and peacetime care available at all NCA MTFs; (4) also, resources available in the local civilian community need to be considered; (5) such a strategy would also provide a systematic basis for justifying budget requests; (6) DOD has recently begun to address this fundamental deficiency; (7) a key obstacle to developing a tri-service strategy is the military services' long-standing independence; (8) historically, the services have had enough resources to maintain separate health care systems, with capabilities overlapping during peacetime; (9) as a result, over the years, formal interservice management efforts have been limited and, today, remain difficult to achieve; (10) a second obstacle is that DOD and the services have not determined the cost of MHS' evolving readiness mission or the cost of its peacetime care; (11) without knowing such costs, DOD is hampered in justifying MHS' size and defending the need for individual MTFs; (12) exacerbating this has been the emerging peacetime care emphasis during this decade--projected to continue in the next--which competes for resources with MHS' basic readiness mission; (13) regarding service coordination with NCA, GAO found that MTFs have entered into numerous, varying agreements to share resources; (14) such ad hoc agreements are vulnerable to changes in MTF budgeting approaches and other factors that can affect the MTFs' willingness to coordinate their efforts; (15) DOD and the services' Surgeons General have undertaken improvement initiatives, including implementing DOD's managed care program, TRICARE; reducing the number of medical personnel; consolidating graduate medical education programs; establishing partnerships with the Department of Veterans Affairs; reducing hospital stays; restructuring hospitals into more efficient clinics; and revising budget processes to more closely link funding to cost-effective health care; and (16) among these the most critical in GAO's and DOD's view is to develop a tri-service strategy that takes into account current and projected beneficiary populations and optimally seeks to realign MTF staffing and resource allocations.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change
from "In process" to "Implemented" or "Not implemented" based on our follow up work.
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Recommendations for Executive Action
Recommendation: To ensure, among other matters, that the defense medical system is properly sized, that inefficiencies and overlaps among MTFs are eliminated, and that readiness is effectively managed, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the services' Surgeons General to complete the development and implementation of a comprehensive tri-service medical resource planning and allocation strategy that clearly defines the cost of readiness and justifies nonreadiness peacetime care based principally on cost-effectiveness analyses.
Agency Affected: Department of Defense
Status: Implemented
Comments: DOD concurred with the recommendation to complete and implement a comprehensive tri-service medical and resource allocation strategy. DOD implemented such a strategy, called Military Health Optimization Plan, in its Northwest TRICARE Region on January 10, 2000, and declared that optimization would be an ongoing process among its military treatment facilities.
Recommendation: To ensure, among other matters, that the defense medical system is properly sized, that inefficiencies and overlaps among MTFs are eliminated, and that readiness is effectively managed, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the services' Surgeons General to emphasize MTF beneficiary enrollment as a key element of tri-service strategy, and make every effort to enroll as many MTF users as possible so that the services and the MTFs can truly manage health care.
Agency Affected: Department of Defense
Status: Implemented
Comments: DOD concurred with the recommendation. In March 2000, the Assistant Secretary of Defense for Health Affairs issued a policy memorandum to improve MTF enrollment capacity. A demonstration was initiated in October 2000, in TRICARE's Region 11 for this purpose. During its visits to Region 11 in October 2001, GAO found MTFs that had initiated activities to increase enrollment and workload at their facilities.
Recommendation: To ensure, among other matters, that the defense medical system is properly sized, that inefficiencies and overlaps among MTFs are eliminated, and that readiness is effectively managed, the Secretary of Defense should direct the Assistant Secretary of defense for Health Affairs and the services' Surgeons General to ensure that the overall strategy identifies and provides for significant care coordination opportunities such as in the NCA.
Agency Affected: Department of Defense
Status: Implemented
Comments: DOD concurred with the recommendation. DOD is identifying and implementing resource sharing opportunities among the medical treatment facilities in its Northwest Region as part of its Optimization efforts. As a result of a two-year demonstration of resource allocation/optimization in DOD's Northwest Region, the TRICARE Management Authority's Director of Resource Management has committed to developing an activity based resource management tool to be submitted with the fiscal year 2004 budget.
Recommendation: To ensure, among other matters, that the defense medical system is properly sized, that inefficiencies and overlaps among MTFs are eliminated, and that readiness is effectively managed, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the services' Surgeons General to work with the line commanders and key stakeholders such as cognizant congressional committees and key members, advocacy groups, and others to obtain support for the implementation of the strategy.
Agency Affected: Department of Defense
Status: Implemented
Comments: DOD concurred and, in their agency comments, stated that actions taken to obtain line commanders and others' support were accomplished.
Recommendation: To ensure, among other matters, that the defense medical system is properly sized, that inefficiencies and overlaps among MTFs are eliminated, and that readiness is effectively managed, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the services' Surgeons General to periodically report progress toward developing and implementing the strategy to cognizant House and Senate committees.
Agency Affected: Department of Defense
Status: Implemented
Comments: DOD concurred with the recommendation. DOD stated that the appropriations committees were given a copy of the optimization plan on September 23, 1999, and that they will brief interested House and Senate committees and subcommittees as requested.
Recommendation: Developing and implementing the tri-service medical resource strategy may require actions by and coordination with other Department of Defense Assistant Secretaries; therefore, as appropriate, the Secretary of Defense should direct the affected Assistant Secretaries' support and participation.
Agency Affected: Department of Defense
Status: Implemented
Comments: In agency comments DOD stated that senior leadership within DOD and the Military Departments had already become engaged and were expected to continue their involvement in the implementation of the optimization plan.
