United States Government Accountability Office Report to Congressional Committees DEFENSE HEALTH June 2023 CARE Improved Monitoring Could Help Ensure Completion of Mandated Reforms GAO-23-105710 June 2023 DEFENSE HEALTH CARE Improved Monitoring Could Help Ensure Completion of Mandated Reforms Highlights of GAO-23-105710, a report to congressional committees Why GAO Did This Study What GAO Found For the past decade, DOD has been The National Defense Authorization Acts (NDAA) for fiscal year 2012 through taking actions to reform its health 2022 contained 158 requirements-actions required for Department of Defense system. The military health system is a (DOD) to take-that GAO identified as reforms of the military health system. massive enterprise charged with GAO placed each requirement into one of five reform categories. maintaining a medically ready force and ready medical personnel. To DOD completed actions to address the majority (approximately 73 percent) of the achieve this mission, DOD estimated it requirements across the five categories (see figure). will provide care to approximately 9.6 million beneficiaries at a cost of more Status of DOD Actions to Address NDAA Requirements than $55.8 billion in fiscal year 2023. The NDAA for Fiscal Year 2022 includes a provision for GAO to study DOD's implementation of statutory requirements for military health system reform. This report examines (1) statutory requirements for reform of the military health system that GAO identified within each NDAA for fiscal years 2012 through 2022, and the extent to which DOD has (2) taken actions to address these requirements for military health system reform and assessed the effectiveness of certain reforms, and (3) monitored actions taken in response to the requirements. Note: GAO assigned each of the NDAAs' 158 requirements to a single category even when a GAO analyzed NDAAs and DOD requirement overlapped with another category. Four requirements were not counted because GAO documentation, and interviewed DOD could not determine DOD's past actions for various reasons, such as information posted online for a senior officials. pilot program that ended. Many of the requirements DOD addressed were from the NDAA for Fiscal Year What GAO Recommends 2017. For example, DOD established the TRICARE Select health plan (as GAO is making four recommendations, required in section 701). Additional work remains for the department to complete including that DOD finalize actions to address the remaining requirements, which include several significant implementation plans for the transfers reforms. For example, GAO found that DOD partially addressed requirements of (1) public health and (2) research from section 711 of the John S. McCain NDAA for Fiscal Year 2019 to establish and development organizations, and public health and research and development organizations within the Defense establish a process to monitor actions Health Agency by September 30, 2022. As of April 2023, Defense Health Agency taken to address statutory officials stated that the transfer of public health personnel was ongoing as DOD requirements for the military health worked to complete Phase I of the transfer. Without finalizing implementation system. DOD concurred with each of plans with timelines for completion and, although not required, providing them to GAO's recommendations. Congress to improve oversight, DOD could be further delayed in addressing these requirements. DOD has processes for delegating responsibility for addressing military health system reform requirements and identifying and tracking requirements for reports and briefings to Congress. However, DOD does not have a systematic process to View GAO-23-105710. For more information, comprehensively monitor actions to address reform requirements. By contact Brenda S. Farrell at (202) 512-3604 or establishing such a process, DOD could improve oversight of its complex, multi- FarrellB@gao.gov. year reform initiatives, including performance of reforms in relation to the MHS goals of better health, better care, improved readiness, and lower costs. United States Government Accountability Office Contents Letter 1 Background 5 National Defense Authorization Acts in Fiscal Years 2012–2022 Mandated 158 DOD Requirements for Military Health System Reform 8 DOD Has Completed Actions to Address Most Requirements, but Additional Work Remains to Complete Some Reforms 12 DOD Does Not Systematically or Comprehensively Monitor Actions Taken in Response to Requirements for MHS Reform 35 Conclusions 41 Recommendations for Executive Action 42 Agency Comments 42 Appendix I Prior GAO Reports Related to Military Health System Reform and Recommendation Status 44 Appendix II Objectives, Scope, and Methodology 48 Appendix III Military Health System Reform Requirements from Fiscal Years 2012 through 2022 that DOD Completed Actions to Address 53 Appendix IV Comments from the Department of Defense 57 Appendix V GAO Contact and Staff Acknowledgments 59 Tables Table 1: Military Health System Reform Requirements from Fiscal Year 2012-2022 National Defense Authorization Acts Requiring an Assessment of Effectiveness 13 Table 2: GAO Reports Related to Military Health System (MHS) Reform and Recommendations Status, As of April 2023 44 Table 3: Military Health System Reform Requirements that DOD Completed Actions to Address, by Category 53 Page i GAO-23-105710 Defense Health Care Figures Figure 1: Categories of Statutorily Mandated Requirements for Military Health System Reform in Fiscal Years 2012-2022 that GAO Identified 9 Figure 2: Number of Military Health System Reform Statutory Requirements for the Department of Defense in Each NDAA, Fiscal Years 2012–2022, by Category 11 Figure 3: Status of DOD's Actions to Address Fiscal Year 2012- 2022 National Defense Authorization Act Requirements Related to Military Health System Reform 12 Figure 4: Status of DOD's Actions to Address Fiscal Year 2012- 2022 National Defense Authorization Act Requirements Related to Governance and Administration 15 Figure 5: Status of DOD's Actions to Address Fiscal Year 2012- 2022 National Defense Authorization Act Requirements Related to Force Structure and End Strength 23 Figure 6: Status of DOD's Actions to Address Fiscal Year 2012- 2022 National Defense Authorization Act Requirements Related to Military Medical Treatment Facility Care 27 Figure 7: Status of DOD's Actions to Address Fiscal Year 2012- 2022 National Defense Authorization Act Requirements Related to Private-Sector Care 28 Figure 8: Elements of Section 705(c) of the National Defense Authorization Act for Fiscal Year 2017 Implemented by DOD in the T-2017 Contracts, as of January 2020 30 Figure 9: Status of DOD's Actions to Address Fiscal Year 2012- 2022 National Defense Authorization Act Requirements Related to Training and Readiness 32 Page ii GAO-23-105710 Defense Health Care Abbreviations DHA Defense Health Agency DOD Department of Defense MHS Military Health System MTF Medical Treatment Facility NDAA National Defense Authorization Act T-5 fifth generation of TRICARE contracts This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page iii GAO-23-105710 Defense Health Care Letter 441 G St. N.W. Washington, DC 20548 June 22, 2023 The Honorable Jack Reed Chairman The Honorable Roger Wicker Ranking Member Committee on Armed Services United States Senate The Honorable Mike Rogers Chairman The Honorable Adam Smith Ranking Member Committee on Armed Services House of Representatives For the past decade, the Department of Defense (DOD) has been carrying out historic reforms of its military health system (MHS) in response to statutory mandates. The MHS is a massive enterprise charged with ensuring that service members are medically ready to deploy and that medical personnel are ready to provide medical care in operational settings. Additionally, the MHS provides medical services and support in non-deployed settings to beneficiaries. 1 In order to achieve this mission, the MHS operates more than 700 military medical treatment facilities (MTF) and networks of private-sector civilian health care providers. DOD estimates that in fiscal year 2023 the MHS will provide health care to approximately 9.6 million beneficiaries-including more than 1.6 million active-duty service members-at a cost of more than $55.8 billion. 2 1Eligible beneficiaries of the MHS are active-duty and retired service members and their families, dependent survivors, and certain reserve component members and their families. 2The $55.8 billion represents the President's unified medical budget request for fiscal year 2023, which includes requests for funding for the Defense Health Program, Military Personnel, and Military Construction accounts. The Defense Health Program funds the following MHS functions: health care delivery in MTFs; TRICARE; certain medical readiness activities and expeditionary medical capabilities; education and training programs; research, development, test, and evaluation; management and headquarters activities; facilities sustainment; procurement; and civilian and contract personnel. Page 1 GAO-23-105710 Defense Health Care The annual National Defense Authorization Acts (NDAA) enacted throughout the past decade have mandated numerous MHS reforms. These reforms cover a variety of operations, including planning for the establishment of the Defense Health Agency (DHA); establishing TRICARE Select-a self-managed, preferred provider organization plan for eligible beneficiaries; and establishing the Joint Trauma System, an effort to improve trauma readiness and outcomes. According to a Senate Armed Services Committee report, reforms have sought to enhance access to high quality healthcare, increase the operational readiness of military medical providers, and lower the per capita costs of health care for DOD. 3 These objectives overlap with DOD's goals for the MHS, referred to as the "Quadruple Aim": better health, better care, lower costs, and increased readiness. We have issued a number of reports about DOD's planning and implementation of some of these MHS reform requirements. For example, we have reported on DOD's efforts to reform the governance of the MHS, including efforts to establish the Defense Health Agency (DHA) and to transition responsibilities for the administration and management of MTFs from the military departments to the DHA. We have also reported on efforts to improve the private-sector care component of the MHS, through which DOD reimburses civilian, private-sector entities for care provided to eligible beneficiaries. Since 2012, we have made at least 88 recommendations to DOD to help oversee its efforts to implement various MHS reform requirements. As of April 2023, DOD has fully or partially implemented 18 of the 88. We discuss our prior work and recommendations throughout this report. Appendix I lists our relevant recommendations since 2012 and the status of each. Section 742 of the NDAA for Fiscal Year 2022 includes a provision for us to examine DOD's actions to address statutory requirements to reform the MHS. 4 This report examines (1) statutory requirements for reform of the MHS that GAO identified within each NDAA from fiscal year 2012 through fiscal year 2022; (2) the extent to which DOD has taken actions to address these requirements and assessed the effectiveness of certain reform actions as required; and (3) the extent to which DOD has 3S.Rep. No. 114-255, at 175-176 (2016). The overall costs for the MHS are projected to reach $69 billion in fiscal year 2037 after increasing by nearly 2 percent per year from 2027 through 2037. Congressional Budget Office, Long-Term Implications of the 2023 Future Years Defense Program (January 2023). 4Pub. L. No. 117-81, § 742, 135 Stat. 1541, 1805-06 (2021). Page 2 GAO-23-105710 Defense Health Care monitored actions taken in response to statutory requirements for MHS reform. For our first objective, we defined "MHS reform" in consultation with DOD officials, and identified the sections that met this definition in the NDAAs from fiscal year 2012 through fiscal year 2022. 5 We then grouped the sections we identified into five categories: Governance and Administration; Force Structure and End Strength; MTF Care; Private- Sector Care; and Training and Readiness. In some instances, requirements overlapped categories; to avoid overcounting, we generally limited the discussion of requirements to one category. We included sections that required the department to assess the effectiveness of reform actions taken. For our second objective, within each of the five categories, we broke down each section we identified as an MHS reform into separate requirements based on actions that the department would need to take to address that particular reform. 6 We reviewed the categorization approach and list of requirements with DOD officials, who agreed without comment. We collected DOD documentation, reviewed our prior work concerning MHS reform, and interviewed DOD officials regarding actions taken to address the requirements. For each requirement, we assessed this information to determine whether the department had completed actions to address the requirement ("Addressed"), had taken actions to partially address the requirement ("Partially Addressed"), or not addressed the 5For the purpose of our review, we define "MHS reform" as enterprise changes affecting the population of beneficiaries, medical providers, and/or administrators (including leadership), or a significant portion thereof and that relate to one or more of the following goals: (1) improving the quality of beneficiary health care, (2) improving the operational readiness of military medical providers, and (3) reducing the cost of the health system overall. 6We considered statutory provisions that require one or more components of DOD to take an action to be a requirement. Conversely, we did not consider the following types of provisions to be reform requirements: (1) provisions that provide discretion in taking action; (2) provisions that provide authority; (3) provisions that outline responsibilities; and (4) provisions that prohibit or limit actions (unless DOD was required to take an action because of a prohibition or limitation). We grouped elements (i.e., any subsections, paragraphs, and subparagraphs) together into one requirement when they were inherently part of the same action. Page 3 GAO-23-105710 Defense Health Care requirement ("Not Addressed"). 7 Two analysts independently reviewed and made determinations, subsequently reconciling any differences in assessments. Our assessments of these requirements includes those that mandated DOD to assess the effectiveness of reform action(s) and provide a report or review to Congress. See appendix II for a detailed description of how we assessed requirements. For our third objective, we discussed with DOD officials their methods for monitoring the status of statutory requirements. In addition, we obtained documentation from various DOD offices about requirements that had been addressed. Specifically, we interviewed officials and collected documents from the Office of the Assistant Secretary of Defense for Health Affairs; DHA; and the Army, Navy, and Air Force medical commands and agencies about their processes for identifying and delegating statutory requirements. For a detailed description of our scope and methodology, see appendix II. We conducted this performance audit from January 2022 to June 2023 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. 7"Addressed" means DOD completed actions to address all elements of the requirement. "Partially addressed" means DOD has taken actions to address some, half, or most of the elements of a requirement, irrespective of whether DOD has completed its actions or plans additional actions to address the requirement. "Not addressed" means DOD did not address any elements of the requirement or has no plans to begin addressing it. In assessing DOD's actions to address requirements, we reviewed our prior work concerning MHS reform to make our determinations. In those cases where we made recommendations that are still open, we noted those recommendations in the report in support of partially addressed or unaddressed requirements. We did not assess the timeliness of any requirements. Finally, we identified four requirements in the Private- Sector Care category that were within our scope of MHS reforms but for which we were unable to determine the extent to which DOD addressed them. This occurred for various reasons, such as information that DOD was required to post online no longer being available. We note these requirements as appropriate in the report, but do not include them in our counts of DOD's actions. For requirements for written products or briefings, we determined that the requirement was addressed if the report or briefing was provided, even if one or more individual elements of the required report or briefing were not included. We discuss some elements of requirements for written products or briefings in this report for illustrative purposes. Page 4 GAO-23-105710 Defense Health Care Background Overview of MHS DOD provides health care services to service members and other eligible beneficiaries worldwide through TRICARE, its regionally structured health care program. TRICARE allows beneficiaries to obtain health care services through DOD's direct care system of military hospitals, medical centers, and clinics-referred to as MTFs-or through private-sector care via civilian network providers. TRICARE offers different benefit options with different cost sharing features for care through the civilian network. 8 With respect to its direct care system infrastructure, DOD estimates it will maintain approximately 700 MTFs (including dental clinics) worldwide in fiscal year 2023. In delivering care to beneficiaries, DOD's facilities also provide essential on-the-job training for active-duty medical providers in support of their operational readiness, along with graduate medical education at some of the largest MTFs. 9 MTFs are also designated to receive wartime casualties, and can provide certain types of assistance to civil authorities during a U.S. national emergency or domestic disaster. In fiscal year 2022, approximately 49,000 active-duty military personnel worked in the MTFs, augmented by about 46,000 federal civilian employees and an estimated 14,500 contracted service providers. Separately, the remainder of DOD's military medical personnel-about 8With the exception of active-duty service members (who are assigned to the TRICARE Prime option and pay no out-of-pocket costs for TRICARE coverage), MHS beneficiaries may have a choice of TRICARE plan options depending upon their status (e.g., active- duty family member, retiree, reservist, child under age 26 ineligible for family coverage, Medicare-eligible) and geographic location. TRICARE options include the following: TRICARE Prime-a health maintenance organization-style option in which beneficiaries typically get most care at an MTF; TRICARE Select-a self-managed, preferred-provider option that allows beneficiaries greater flexibility in managing their own health care and typically does not require a referral for specialty care; and TRICARE for Life-coverage provided to certain retired TRICARE beneficiaries who must enroll in Medicare and pay Medicare Part B premiums to retain TRICARE coverage. 9For purposes of this report, operational medical force readiness refers to the ability of medical providers-based on their knowledge, skills, and abilities-to meet DOD's operational mission needs and provide those capabilities to combatant commanders. Medical readiness refers to the physical and mental health and fitness of military service members to perform their missions. In order to sustain the medical skills of its providers, DOD policy states that medical services provided within the direct care system of the MHS be prioritized over other types of training. When workload within the direct care system is insufficient, DOD has taken steps to augment this training with additional training modalities, including through the development of training partnerships with civilian medical facilities and the use of medical simulation. Department of Defense Instruction 6000.19, Military Medical Treatment Facility Support of Medical Readiness Skills of Health Care Providers (Feb. 7, 2020). Page 5 GAO-23-105710 Defense Health Care 39,000 in fiscal year 2022-were assigned to various duties outside of the MTFs. To provide private-sector care, DOD contracts with private-sector companies-referred to as managed care support contractors-in each of its two TRICARE regions (East and West). These companies are to develop and maintain networks of civilian providers and perform other customer service functions, such as processing claims, enrolling beneficiaries, and assisting beneficiaries with finding providers. In fiscal year 2023, appropriated amounts for private-sector care totaled approximately $18.6 billion, or about 47 percent of the Defense Health Program appropriation. 10 In December 2022, DHA, which administers the TRICARE program, awarded its fifth generation of TRICARE contracts, referred to as the T-5 contracts. Roles and Responsibilities Various components share the responsibility for health care delivery within the MHS within the MHS, including the Office of the Secretary of Defense, the military departments, and the DHA. As such, multiple officials and organizations are responsible for DOD's medical personnel, their readiness, and the MTFs to which many of them are assigned. The Under Secretary of Defense for Personnel and Readiness is the principal staff assistant and advisor to the Secretary of Defense for health-related matters and, in that capacity, develops policies, plans, and programs for health and medical affairs. 11 The Assistant Secretary of Defense for Health Affairs serves as the principal advisor to the Under Secretary of Defense for Personnel and Readiness for all DOD health-related policies, programs, and activities. 12 The Assistant Secretary of Defense for Health Affairs has the authority to 10The cost of private-sector care is increasing as a share of DOD's total operation and maintenance cost for the Defense Health Program, which also includes the cost of operating MTFs and providing medical personnel training, among other things. Specifically, based on DOD budget justification documentation, from fiscal year 2016 through fiscal year 2023, the appropriated amounts for private-sector care increased from about 48 percent to about 52 percent, respectively, relative to the total appropriated operation and maintenance amounts for the Defense Health Program over those fiscal years. 11Department of Defense Directive 5124.02, Under Secretary of Defense for Personnel and Readiness (USD(P&R)) (June 23, 2008). 12Department of Defense Directive 5136.01, Assistant Secretary of Defense for Health Affairs (ASD(HA)) (Sept. 30, 2013) (incorporating change 1, Aug. 10, 2017). Page 6 GAO-23-105710 Defense Health Care develop policies, conduct analyses, provide advice, and make recommendations to the Secretary of Defense and others; issue guidance; and provide oversight on matters pertaining to the MHS. Further, the Assistant Secretary of Defense for Health Affairs is to prepare and submit a DOD unified medical program budget that includes, among other things, the Defense Health Program budget to provide resources for MTFs and the TRICARE Health Program. The Secretaries of the military departments are responsible for organizing, training, and equipping military forces-including medical personnel-as directed by the Secretary of Defense. They are also responsible for ensuring the readiness of military personnel and providing military personnel and authorized resources in support of the combatant commanders and the DHA. • Each military department maintains one or more commands or agencies, which are responsible for developing and maintaining the readiness of medical personnel. These include the U.S. Army's Medical Command and the Medical Center of Excellence within the U.S. Army Training and Doctrine Command, the Navy's Bureau of Medicine and Surgery, and the Air Force Medical Readiness Agency. • The Surgeon General of each respective military department serves as the principal advisor to the Secretary of the military department concerning all health and medical matters of the military department. The Director of the DHA manages, among other things, the execution of policies issued by the Assistant Secretary of Defense for Health Affairs and manages and executes the Defense Health Program appropriation. 13 The Director of the DHA is also responsible for the TRICARE Health Program. In December 2016, the NDAA for Fiscal Year 2017 expanded the role of the DHA by directing the transfer of responsibility for the administration of each MTF from the military departments to the DHA by September 30, 2021. 14 13Department of Defense Directive 5136.13, Defense Health Agency (DHA) (Sept. 30, 2013) (incorporating change 1, Mar. 2, 2022). 1410 U.S.C. § 1073c(a)(1). Initially, the transfer of responsibilities to the DHA was to occur by October 1, 2018. However, in August 2018, the John S. McCain NDAA for Fiscal Year 2019 amended 10 U.S.C. § 1073c to require this transition to occur by September 30, 2021. Pub. L. No. 115-232, § 711 (2018). Page 7 GAO-23-105710 Defense Health Care Across the NDAAs from fiscal year 2012 through 2022, we identified 158 National Defense specific statutory requirements for MHS reform in 39 different sections of Authorization Acts in those NDAAs. 15 Each statutory requirement was unique and varied in the level of effort required to address it. For example, some statutory Fiscal Years 2012– requirements call for the establishment of a program, while others require 2022 Mandated 158 a report to Congress. For the purposes of this report, we categorized these requirements into five reform areas: 1) Governance and DOD Requirements Administration, 2) Force Structure and End Strength, 3) MTF Care, 4) for Military Health Private-Sector Care, and 5) Training and Readiness. 16 Some System Reform requirements overlapped categories, which we discuss later in this report as appropriate. We counted each requirement once, and discussed each requirement under one category. Figure 1 describes these categories and provides examples of requirements. 15We determined that a requirement existed if it required DOD to take an action to implement the law. We excluded from our scope one section that was repealed. All other requirements we identified remain in force, and we assessed the status of actions taken for requirements as amended through the NDAA for Fiscal Year 2022, where applicable. 16See appendix II for a full description of our methodology to define military health system reform and to identify and categorize requirements. Page 8 GAO-23-105710 Defense Health Care Figure 1: Categories of Statutorily Mandated Requirements for Military Health System Reform in Fiscal Years 2012-2022 that GAO Identified Note: Although some requirements overlap categories of reform, we assigned each requirement to a single category and counted each requirement once. Additionally, we identified four requirements in the Private-Sector Care category that were within our scope of reforms but for which we were unable to determine the extent to which DOD addressed them because, for example, the information that DOD was required to post online no longer being available. We do not include these requirements in our counts of DOD's actions. Page 9 GAO-23-105710 Defense Health Care a Pub. L. No. 112-239, § 731 (2013). b Pub. L. No. 114-328, § 730 (2016). c Pub. L. No. 114-328, § 721 (2016), codified at 10 U.S.C. § 977. d Pub. L. No. 116-92, § 719 (2019). e Pub. L. No. 114-328, § 709(a) (2016). f Pub. L. No. 114-328, § 709(d) (2016). g Pub. L. No. 114-328, § 701(a) (2016), codified at 10 U.S.C. § 1075. h Pub. L. No. 114-328, § 701(h) (2016). Pub. L. No. 114-328, § 708 (2016). i j Pub. L. No. 114-328, § 749 (2016). We found that the numbers and types of requirements for MHS reform varied over time in the NDAAs. For example, the majority of requirements overall were enacted in the NDAA for Fiscal Year 2017. The majority of requirements related to the governance and administration of the MHS were directed in the fiscal years 2017 and 2019 NDAAs. Force structure and end strength requirements were largely directed in the NDAAs for fiscal year 2020 through 2022 (see fig. 2). Page 10 GAO-23-105710 Defense Health Care Figure 2: Number of Military Health System Reform Statutory Requirements for the Department of Defense in Each NDAA, Fiscal Years 2012–2022, by Category Note: Although some requirements have attributes of more than one category of reform, we assigned each requirement to a single category and counted each requirement once. Additionally, we identified four requirements in the Private-Sector Care category that were within our scope of reforms but for which we were unable to determine the extent to which DOD addressed them because, for example, the information that DOD was required to post online was no longer available. We do not include these requirements in our counts of DOD's actions. Of the 158 requirements we identified related to MHS reforms, seven included language requiring DOD to assess the effectiveness of reform actions. For example, DOD was required to conduct a pilot program that allowed covered beneficiaries to access urgent care visits without the need for preauthorization and report to Congress on this effort. 17 17Pub. L. No. 114-92, § 725 (2015). Page 11 GAO-23-105710 Defense Health Care DOD has completed actions to address most statutory requirements for DOD Has Completed MHS reform that we identified in NDAAs for fiscal year 2012 through Actions to Address 2022, including those to assess reform actions. However, additional work remains to address some requirements in each category of reform. Most Requirements, but Additional Work Remains to Complete Some Reforms DOD Has Completed DOD has completed actions to address approximately 73 percent (115) of Actions to Address Most the 158 NDAA requirements directing reforms of the MHS. Additionally, DOD has taken actions that partially addressed about 25 percent (40) of Statutory MHS Reform the NDAA requirements, but has not addressed approximately 2 percent Requirements, Including (three) of them. 18 Figure 3 provides an overview of DOD's efforts to Those to Assess Reform address these statutory requirements, including the seven that required Actions DOD to assess the effectiveness of actions taken to meet them. Figure 3: Status of DOD's Actions to Address Fiscal Year 2012-2022 National Defense Authorization Act Requirements Related to Military Health System Reform Note: Although some requirements have attributes of more than one category of reform, we assigned each requirement to a single category and counted each requirement once. Additionally, we identified four requirements in the Private-Sector Care category that were within our scope of reforms but for which we were unable to determine the extent to which DOD addressed them because, for example, the information that DOD was required to post online was no longer available. We do not include these requirements in our counts of DOD's actions. 18In assessing DOD's actions to address statutory requirements for MHS reforms, we did not assess the quality of actions taken to address requirements. In a few instances, requirements overlapped categories, which we indicate accordingly. We counted each requirement once, and discussed each requirement under one category. Page 12 GAO-23-105710 Defense Health Care Of the 115 requirements that DOD has completed actions to address, many of them were in the NDAA for Fiscal Year 2017. For example, DOD established the TRICARE Select health plan (as required in section 701); 19 provided Congress with implementation plans for the transition of MTFs to the DHA (as required in section 702); and established a Joint Trauma System and Joint Trauma Education and Training Directorate within DHA (as required in sections 707 and 708). Appendix III includes a complete list of these and other requirements that DOD completed actions to address. Of the 158 requirements we identified related to MHS reforms, seven-all related to Private- Sector Care-included language requiring DOD to assess the effectiveness of reform actions. We found that DOD has completed actions to address six of these statutory requirements and had not yet addressed one requirement. See Table 1 for an overview of requirements that included language requiring DOD to assess the effectiveness of reform actions. Table 1: Military Health System Reform Requirements from National Defense Authorization Acts for Fiscal Years 2012-2022 Requiring an Assessment of Effectiveness Subsection and NDAA Public law paragraph (if Number of Requirement details and status fiscal year number applicable) requirements Addressed. Section 725 requires DOD to submit 2016 114-92 (c)(1) – (2) 2 two reports assessing a pilot program on urgent care access under TRICARE private-sector care.a DOD provided these reports to Congress on Sept. 11, 2017 and June 14, 2018, respectively. Addressed. Section 726 requires DOD to submit 2016 114-92 (d)(1) – (2) 2 two reports assessing a pilot program on value- based incentive programs under TRICARE private-sector care. DOD provided these reports to Congress on Jan. 11, 2018 and Feb. 18, 2020, respectively. Not Addressed. Section 701 requires DOD to 2017 114-328 (h)(5) 1 submit a report assessing a pilot program on implementing a value-based health care methodology under TRICARE private-sector care for beneficiaries receiving high-value medications and services and the use of high-value providers. DOD has not yet completed this report, which was due to Congress no later than Jan. 1, 2023. 19This requirement is codified, as amended, at section 1075 of title 10, United States Code. Page 13 GAO-23-105710 Defense Health Care Subsection and NDAA Public law paragraph (if Number of Requirement details and status fiscal year number applicable) requirements Addressed. Section 718 requires DOD to submit 2017 114-328 (e)(2) 1 a report assessing the impact of DOD incorporating the use of telehealth services in the military health system. DOD provided this report to Congress on Aug. 17, 2022. Addressed. Section 729 requires DOD to submit 2017 114-328 (d) 1 a report assessing programs incentivizing beneficiary participation in medical and lifestyle programs. DOD provided this report to Congress on March 3, 2021. Source: GAO analysis of National Defense Authorization Acts (NDAA) and Department of Defense (DOD) information. | GAO-23-105710 a Section 725(c)(3) of the NDAA for Fiscal Year 2016 requires a third and final report to be issued not later than 180 days after the completion of the pilot program. However, a third report was not prepared because section 704(a) of the NDAA for Fiscal Year 2017 made access to urgent care permanent. Therefore, we did not include a third report in our count of requirements. Additional Work Remains Of the 158 NDAA requirements we identified that direct MHS reforms, to Address Some MHS DOD has not completed actions that would fully address 43 requirements, but has planned to take actions toward completing many of them. Reform Requirements Specifically, of the 43 requirements, DOD has taken actions to partially address 40 requirements, which are distributed across the five categories of reform. Furthermore, it has not addressed the other three requirements, which relate to Governance and Administration, Force Structure and End Strength, and Private-Sector Care. We describe the status of DOD's actions to address these 43 requirements in more detail below, by category. Governance and DOD has completed actions to address approximately 76 percent of the Administration requirements (28 of 37) related to governance and administration and has taken actions to partially address nearly 22 percent (eight of 37). Finally, it has not taken actions to address about 3 percent (one of 37), as shown in figure 4. Page 14 GAO-23-105710 Defense Health Care Figure 4: Status of DOD's Actions to Address National Defense Authorization Acts for Fiscal Years 2012-2022 Requirements Related to Governance and Administration The nine partially- and not-addressed requirements are found in five NDAA sections. These nine requirements relate to (1) MTF advisory committees, (2) congressional briefings on the proposed elimination of inpatient MTF capabilities, (3) new organizations within DHA for public health and research and development, (4) the feasibility of a new DHA organization for education and training, (5) DHA's organizational framework, and (6) MTF staffing. 20 Establishment of Advisory Committees for MTFs. Section 731 of the NDAA for Fiscal Year 2017 requires the Secretary of Defense to establish, under such regulations as the Secretary may prescribe, an advisory committee for each military treatment facility. We found that DOD had partially addressed this requirement. DHA issued guidance in 2019 requiring that all parent-level MTFs (i.e., large MTFs, such as community hospitals, that are connected to smaller surrounding clinics) establish an advisory committee that they call a Patient and Family Partnership Council. 21 According to DHA records updated in March 2023, 94 of 132 parent-level MTFs had an advisory committee, 18 were re- establishing one, and 14 did not maintain one. DHA officials told us they were confirming the status of the remaining six MTF committees. 20The following NDAA sections contain the requirements that DOD had not yet completed actions to address: one requirement in section 731 of the NDAA for Fiscal Year 2017; one requirement in section 711 of the NDAA for Fiscal Year 2018; three requirements in section 711 of the NDAA for Fiscal Year 2019; three requirements in section 712 of the NDAA for Fiscal Year 2019; and one requirement in section 712 of the NDAA for Fiscal Year 2022. 21Defense Health Agency Interim Procedures Memorandum 19-002, Standard Processes for Establishing and Maintaining Patient and Family Partnership Councils (PFPC) as Advisory Committees at Military Medical Treatment Facilities (MTF) (Feb. 12, 2019). Page 15 GAO-23-105710 Defense Health Care A senior DHA official provided several reasons why these parent-MTFs did not currently have an advisory committee. Specifically, the official said that multiple committees have not reconvened following a temporary pause in response to the COVID-19 pandemic, though DHA is working to reestablish these. The official stated that others did not currently have a committee because DHA was in the process of determining if geographically-close MTFs can share one. Briefing on proposed elimination of inpatient capabilities at MTFs outside the United States. Section 711 of the NDAA for Fiscal Year 2018 amended section 1073d of title 10, United States Code, to require the Secretary of Defense to provide a briefing to the House and Senate Armed Services Committees before eliminating inpatient capabilities at any facility located outside the continental United States. 22 In the required briefings, the Secretary must certify that specific actions have been taken and will be taken prior to the elimination of inpatient capabilities. 23 As of April 2023, DOD had not addressed this requirement. Specifically, we found that the Air Force eliminated the inpatient capabilities of the MTF at Aviano Air Force Base in May 2018-approximately 5 months after the NDAA for Fiscal Year 2018 was enacted-without the required briefing. According to Air Force officials, the Surgeon General of the Air Force provided an informal notification-but not the required briefing-to Congress in January 2018. Officials added that a draft briefing is currently being coordinated with DHA and the Joint Staff for review and comment. However, the briefing had not yet been completed and delivered to the required congressional committees at the time of our report. According to Air Force officials, there are a few reasons that the briefing had not yet been provided to Congress. First, Air Force officials told us they initially believed they had addressed the requirement through an informal notification to Congress. Officials stated that they later determined that a formal briefing was required because the informal 22Pub. L. No. 115-91, § 711 (2017). Section 711 of the NDAA for Fiscal Year 2018 amended 10 U.S.C. § 1073d by adding subsection (e). 23Before inpatient capabilities are eliminated, the Secretary must certify the following: that the Secretary has entered into agreements with medical facilities in the host nation to replace the eliminated inpatient capabilities and ensure beneficiaries have access to quality health care; that the Secretary has consulted the appropriate geographic combatant command to ensure that the proposed elimination will not impact the geographic combatant command's operational plan; and that the Secretary shall provide each affected beneficiary with a transition plan for continuity of health care and a public forum to discuss their concerns. 10 U.S.C. § 1073d(e). Page 16 GAO-23-105710 Defense Health Care notification did not contain required details. Second, Air Force officials told us that the draft briefing to fulfill the section 711 requirement has undergone additional review in response to a new, related mandate in section 715 of the NDAA for Fiscal Year 2023 that requires additional congressional notification requirements for any MTF that DOD proposes modifying. 24 However, the officials could not guarantee when they would complete their review, and 5 years have passed since the Air Force eliminated the inpatient capabilities from the MTF at Aviano Air Force Base. Until DOD provides the required briefing, Congress will lack details about the rationale for modifications to this facility and assuredness that beneficiaries' access to care has not been negatively affected. Requirements regarding the establishment of DHA Public Health and DHA Research and Development organizations. Section 711 of the NDAA for Fiscal Year 2019 requires that, by September 30, 2022, the Secretary of Defense establish within the DHA two new organizations: (1) DHA Public Health, to be led by a director or commander and comprised of the military departments' public health centers or programs; and (2) DHA Research and Development, to be led by a director or commander and comprised of the Army Medical Research and Materiel Command. 25 Additionally, section 712 of the NDAA for Fiscal Year 2022 requires the Secretary of Defense to conduct recurring consultations with each military department as it establishes DHA's Research and Development organization, and to consult with the military departments on at least a 24James M. Inhofe National Defense Authorization Act for Fiscal Year 2023, Pub. L. No. 117-263, § 715 (2022). Section 715 of the NDAA for Fiscal Year 2023 amended 10 U.S.C. § 1073d by introducing subsection (f). This subsection requires the Secretary of Defense to provide the House and Senate Armed Services Committees with notification of any proposed modification of an MTF's scope of medical care before those modifications occur. If such modification involves termination or reduction of inpatient capabilities at an MTF outside the United States, the notification must also indicate that the Secretary has provided to each affected beneficiary a transition plan for the continuity of health care. Finally, the notification must also contain information demonstrating the extent to which the commander of the military installation of the affected facility has been consulted to ensure there will be no impact on the operational plan for the installation. 25Pub. L. No. 115-232, § 711 (2018), codified as amended at 10 U.S.C. § 1073c(e). Section 711 also states that DHA Research and Development shall also be comprised of any other medical research organizations and activities of the armed forces as the Secretary of Defense considers appropriate. DHA Public Health is to be comprised of the Army Public Health Center, the Navy-Marine Corps Public Health Center, Air Force public health programs, and any other related defense health activities that the Secretary of Defense considers appropriate. Page 17 GAO-23-105710 Defense Health Care semi-annual basis thereafter. 26 As of April 2023, DOD has taken actions to partially address these three requirements. • DHA Public Health organization. DHA's Campaign Plan for fiscal years 2022 through 2026 states that it will be responsible for managing, executing, and delivering public health support by fiscal year 2026. To that end, the DHA Director appointed a Director of DHA Public Health in February 2022. Additionally, on October 31, 2022, the military departments transferred authority, direction, and control of selected public health functions within the 1) Army Public Health Center, 2) Navy and Marine Corps Public Health Center, and 3) selected Air Force public health programs within the U.S. Air Force School of Aerospace Medicine to DHA as a part of Phase I of the transfer. However, DHA officials stated that, as of April 2023, DHA and the military departments were in the process of executing Phase I of the transfer to realign personnel, property, and systems to DHA Public Health. • DHA Research and Development organization. As with DHA Public Health, DHA's Campaign Plan for fiscal years 2022 through 2026 states that it will be responsible for managing, executing, and delivering military medical research and development by fiscal year 2026. According to a senior DHA official, DOD has programmed and budgeted for the transfer of U.S. Army Medical Research and Development Command personnel to DHA for fiscal years 2024 through 2026. However, as of April 2023, the official stated neither functions nor personnel had been transferred from the U.S. Army Medical Research and Development Command to the new DHA organization. DOD officials were unable to provide a timeline- including milestones or targets-for the completion of the transfer process. The Secretary has also not appointed a Director. With respect to the required consultations between the Secretary and each military department as it establishes DHA Research and Development, officials stated that DOD leaders approved a new governance structure to address this requirement, and the first meeting of the new forum is planned for May 2023. Until then, officials stated that the military departments will continue to coordinate with DHA on medical research through existing forums. DOD was required to establish the public health and research and development organizations within DHA by September 2022. However, DHA currently expects to complete its establishment by fiscal year 2026. 26Pub. L. No. 117-81, § 712 (2021), codified at 10 U.S.C. § 1073c(f). Page 18 GAO-23-105710 Defense Health Care With respect to DHA Public Health, DHA officials stated that they have begun developing an implementation plan for Phase 2 of the transfer of functions from the military departments. However, officials added that these efforts were paused in response to section 720 of the NDAA for Fiscal Year 2023, which provides the military departments, at the discretion of the Secretary of Defense, the ability to temporarily retain, until not later than February 1, 2024, public health functions under specified conditions. 27 Similarly, DHA officials stated that they have begun to develop a detailed implementation plan for the transfer of research and development functions from the military departments to DHA, but that the plan has not been finalized. DHA officials explained that they were waiting on key decisions from senior DOD leaders about timelines for remaining functions to be transferred for both organizations, to include personnel transfers. Leading practices associated with successful reform efforts state that developing an implementation plan with key milestones and deliverables can help an organization track implementation progress. 28 Without finalized implementation plans with timelines for completion of the remaining phases of both the public health transfer and the transfer of research and development, DOD could be further delayed in implementing the transfer of these public health and research and development functions from the military departments to the DHA. Although DOD was not required to provide the plans to Congress, doing so would enhance congressional oversight of these multi-year transition processes to ensure their continued progress. Feasibility of establishing Defense Health Agency Education and Training. Section 711 of the NDAA for Fiscal Year 2019 requires a report regarding the feasibility of establishing DHA Education and Training, 27Pub. L. No. 117-263, § 720 (2022). Under section 720, a military department may retain a covered function if the Secretary of Defense determines that it addresses a need that is unique to the military department and is in direct support of operating forces and necessary to execute strategies relating to national security and defense. 28GAO, Government Reorganization: Key Questions to Assess Agency Reform Efforts, GAO-18-427 (Washington, D.C.: June 13, 2018). Page 19 GAO-23-105710 Defense Health Care which DOD took action to partially address. 29 DOD provided the report to the House and Senate Armed Services Committees. However, while the report demonstrated information on the size and complexity of the military medical education and training system, it did not provide a determination regarding the feasibility of establishing DHA Education and Training. Instead, the report noted that the medical education and training enterprise is large, complex, and decentralized, and stated that the department will conduct a more comprehensive assessment of restructuring DOD's medical education and training enterprise after ongoing MHS reform activities are completed. Section 724 of the NDAA for Fiscal Year 2023 requires DOD to conduct another feasibility study for an organization to be known as the MHS Education and Training Directorate, and develop a plan for the establishment of the directorate. 30 DOD is required to submit the study and plan to the House and Senate Armed Services Committees by December 23, 2023. Establishment of DHA organizational framework. Section 712 of the NDAA for Fiscal Year 2019 requires the Secretary of Defense to develop an MHS organizational framework that supports the medical requirements of the combatant commands. 31 Specifically, section 712 requires that there should be no more than two DHA regions in the continental United States, and no more than two DHA regions outside the United States. DOD has partially addressed this requirement. The department established two DHA regions outside the United States consistent with the requirement-DHA Region Europe and DHA Region Indo-Pacific. However, it implemented a geographically based DHA structure 29The report was to include information on the feasibility of establishing a new organization, to be led by the President of the Uniformed Services University of the Health Sciences and to be comprised of the current Medical Education and Training Campus located at Fort Sam Houston, the Uniformed Services University of the Health Sciences, the medical education and training commands of the Armed Forces, and such other elements, facilities, and commands of DOD as the Secretary of Defense considers appropriate. Pub. L. No. 115-232, § 711 (2018). 30Pub. L. No. 117-263, § 724 (2022). 31Pub. L. No. 115-232, § 712(a) (2018). Section 712(b) also specified that each DHA region within the United States shall be led by a commander or director who is a member of the Armed Forces and serving in a grade not higher than major general or rear admiral. Further, each commander or director shall be selected by the Director of the DHA from among members of the Armed Forces recommended by the Secretaries of the military departments for service in such position, and shall be under the authority, direction, and control of the Director while serving in such position. DOD addressed this provision of the requirement. Page 20 GAO-23-105710 Defense Health Care comprised of 19 large markets, 17 small markets, and 40 standalone parent MTFs within the continental United States. 32 DHA does not use the term "region" to define its U.S.-based organizational framework, but we found that the markets share key similarities with the overseas regions. We have ongoing work related to DHA's management structure for MTFs. We plan to issue a report in the summer of 2023. 33 Coordination to ensure MTF staffing supports readiness, and validation of supply and demand for medical services at MTFs. Section 712 of the NDAA for Fiscal Year 2019 also requires the DHA Director to coordinate with the military departments to ensure that staffing at MTFs in each region supports medical readiness requirements for service members of the Armed Forces and military medical personnel. 34 Additionally, it mandates that the DHA Director (1) validate supply and demand requirements for medical and dental services at each MTF and, when the workload is insufficient to meet requirements, (2) identify alternative training and clinical practice sites for uniformed medical and dental personnel and establish military-civilian training partnerships. DHA has taken actions to partially address these two requirements. Specifically, DHA and the military departments developed a process called the Human Capital Distribution Framework by which to coordinate military medical personnel assignments across all MTFs. However, they had not fully implemented the new process as of April 2023. According to a senior DHA official, DHA and the military departments implemented the process for a subset of personnel and MTFs in 2021. The official expected that the process would be implemented for all personnel and MTFs in the summer of 2023. Consistent with the statutory requirement, the process was designed to account for the staffing levels needed to support readiness requirements and uses historical data on demand for health care services. In addition to this effort to meet the statutory requirement, MTFs submit performance plans to DHA that identify the demand for healthcare services, the supply of providers to meet this 32Parent MTFs are larger facilities-such as community hospitals-that are connected to smaller surrounding clinics. DOD also maintains 36 subordinate clinics reporting to 21 of the standalone parent MTFs. DHA's market offices, including its Small and Stand-Alone MTF Organization, as well as its regional offices for the DHA Region Europe and DHA Region Indo-Pacific, handle administration and management activities for the their constituent MTFs. 33See GAO-23-105441, when available. 34Pub. L. No. 115-232, § 712 (2018). Page 21 GAO-23-105710 Defense Health Care demand, and mitigation strategies to address gaps in the ability to meet demand. This includes identifying MTF personnel available to support health service delivery when service readiness activities take providers outside the MTF. 35 With respect to identifying alternative training when MTF workload is insufficient, we found that DHA has taken steps to facilitate the development of military-civilian training partnerships, pursuant to DOD guidance. 36 This work has been limited to partnerships for trauma-related training, according to DHA officials. Specifically, DHA's Joint Trauma Education and Training Branch-a branch of DHA's Joint Trauma System-has developed criteria to evaluate civilian academic trauma center partnerships opportunities for use by trauma teams of the military departments. However, in December 2022, DHA officials stated that they had not yet established partnerships. Instead, military MTF leaders have locally developed the majority of partnerships, augmented by military department medical organizations, which-according to officials- established other MTF partnerships with civilian hospitals. Because the transition of MTF administration and management to the DHA occurred from 2019 through 2022, DHA's market offices now manage partnerships, including the continuation of preexisting partnerships and the creation of new ones. 37 We continue to believe that fully implementing our prior recommendation that the DHA Director establish a process to streamline or add new military-civilian training partnerships would help DOD facilitate these partnerships and ensure its alignment with statutory responsibilities. Force Structure and End DOD has completed actions to address approximately 59 percent of the Strength requirements (10 of 17) related to force structure and end strength and 35According to DHA documentation, markets will submit one plan for fiscal years 2023 through 2025 for all MTFs and dental activities within their market. Plans should contain information on proposed initiatives to address gaps and are reviewed at various levels within DHA and the services, including reviews for readiness implications. Ultimately, initiatives recommended as a result of various reviews are briefed to DHA's Assistant Director, Health Care Administration, for approval. 36DOD Instruction 6000.19. 37In June 2021, we reported that the DHA did not have a process to streamline or add new military-civilian training partnerships and recommended that the Secretary of Defense ensure that the DHA Director establish such a process. GAO, Defense Health Care: Actions Needed to Define and Sustain Wartime Medical Skills for Enlisted Personnel, GAO-21-337 (Washington, D.C.: June 21, 2021). DOD concurred with this recommendation but has not yet implemented it as of April 2023. Page 22 GAO-23-105710 Defense Health Care has taken actions to partially address approximately 35 percent of them (six of 17). Finally, it has not taken actions to address about 6 percent of the requirements (one of 17), as shown in figure 5. Figure 5: Status of DOD's Actions to Address National Defense Authorization Acts for Fiscal Years 2012-2022 Requirements Related to Force Structure and End Strength The six partially-addressed requirements and the one not addressed are found in three NDAA sections and relate to (1) defining medical and dental personnel requirements, (2) developing a measure of network adequacy, and (3) reporting on force mix options. Process to define military medical and dental personnel requirements. Section 721 of the NDAA for Fiscal Year 2017 requires the Secretary of Defense, in collaboration with the military departments, to (1) establish a process to define military medical and dental personnel requirements necessary to meet operational medical force readiness requirements, and (2) report to the House and Senate Armed Services Committees on the process and the defined personnel requirements. 38 Further, section 719 of the NDAA for Fiscal Year 2020 requires each of the three military departments to review medical personnel requirements, in coordination with the Joint Chiefs of Staff, including any requirements 38Pub. L. No. 114-328, § 721 (2016). Section 721 codified the requirement for a process at section 977 of title 10, United States Code. Page 23 GAO-23-105710 Defense Health Care determined pursuant to estimates provided in the Joint Medical Estimate. 39 DOD took actions to partially address four requirements related to personnel in these two sections. Specifically, DOD provided the House and Senate Armed Services Committees with interim and final reports on the two sections. In its March 2018 interim report, DOD stated that the individual military departments completed the majority of the work to define personnel requirements in coordination with the Joint Staff, and that additional work was required to develop a DOD-wide process. 40 The interim report also noted that DOD would address a department-wide process in a follow-on report to the House and Senate Armed Services Committees. However, in its final report in August 2021, DOD restated its description of the processes the military departments use to identify requirements individually, having not established the singular DOD-wide joint process that it described working toward in its interim report to address the requirement in section 721. 41 Moreover, according to the Joint Staff Surgeon, the military departments' respective analyses did not fully address Joint Staff comments, including input from the Joint Medical Estimate. 42 Our prior work reviewed DOD's progress toward addressing section 721. We reported in February 2019 that, among other things, the military 39Pub. L. No. 116-92, § 719 (2019), as amended by Pub. L. No. 116-283, § 717 (2021) and Pub. L. No. 117-81, § 731 (2021). The Joint Medical Estimate is an independent assessment, prepared by the Joint Staff Surgeon, of the Joint Force's operational medical capabilities in support of the National Military Strategy, and provides potential shortfalls and barriers to providing health care to service members during the full range of military operations. Chairman of the Joint Chiefs of Staff Instruction 3100.01E, Joint Strategic Planning System (May 21, 2021). 40Department of Defense, Substantive Interim Report to the Armed Services Committees of the Senate and House of Representatives, Section 721 of the National Defense Authorization Act for Fiscal Year 2017 (Public Law 114–328), Authority to Convert Military Medical and Dental Positions to Civilian Medical and Dental Positions (March 2018). 41Department of Defense, Report to the Congressional Armed Services Committees, Section 719 of the National Defense Authorization Act for Fiscal Year 2020, (Public Law 116 – 92) (July 2021). DOD states in this final report that the report addresses the remaining requirements in section 721 of the NDAA for Fiscal Year 2017, in addition to requirements in section 719 of the NDAA for Fiscal Year 2020. 42We have ongoing work on the military departments' use of the Joint Medical Estimate in their processes to determine medical personnel requirements. We plan to issue a report on this topic later this year. See GAO-23-106094, when available. Page 24 GAO-23-105710 Defense Health Care departments applied different planning assumptions in estimating required personnel, such as developing varying definitions for operational requirements. 43 We recommended that DOD (1) establish joint planning assumptions for developing operational medical and dental personnel requirements, (2) establish a method to assess options for achieving joint efficiencies in those requirements, and (3) apply joint planning assumptions and a method for assessing efficiencies and risk to determine requirements. DOD concurred with these recommendations. As of April 2023, DOD had not fully implemented the three recommendations. We continue to believe that fully implementing these recommendations will help align DOD's actions with statutory requirements. Until DOD fully implements the recommendations, the department will not be able to apply consistent assumptions to determine medical and dental personnel requirements and will not have a method for assessing options for joint efficiencies. Without such a method, the department will not know whether it has an optimal size and composition of medical and dental personnel for achieving its missions within acceptable risk levels. Development and use of a network adequacy measure. Section 719 of the NDAA for Fiscal Year 2020 also requires the Secretary of Defense to develop a standard measurement for network adequacy to determine the capacity of the local health care network to provide care for covered beneficiaries in the area of an MTF that would be affected by a proposed military medical end strength realignment or reduction. Additionally, section 719 requires that the Secretary use such measurement in carrying out this section and otherwise evaluating proposed military medical end strength realignment or reductions. DOD took actions to partially address these two requirements. In May 2020, we reported that DOD had not decided how to define and measure its objectives for MTF restructuring transitions, including an objective to ensure that civilian health care facilities and providers adequately support the health care needs of beneficiaries near each MTF. 44 We recommended that DOD collect complete and accurate 43GAO, Defense Health Care: Actions Needed to Determine the Required Size and Readiness of Operational Medical and Dental Forces, GAO-19-206 (Washington, D.C.: Feb. 21, 2019). 44GAO, Defense Health Care: Additional Information and Monitoring Needed to Better Position DOD for Restructuring Medical Treatment Facilities, GAO-20-371 (Washington, D.C.: May 29, 2020). Page 25 GAO-23-105710 Defense Health Care information about civilian health care providers and define measurable objectives, among other things. DOD concurred or partially concurred with, but has not yet fully implemented, these recommendations. In its final report on sections 721 and 719, DOD defined network adequacy and described a methodology for assessing it. We have ongoing work related to the sufficiency of DOD's methodology and the extent they used it to assess the ability of local health care networks to absorb additional workload caused by military medical reductions. We plan to issue a report later this year. 45 Report on force mix options and service models. Section 757 of the NDAA for Fiscal Year 2021 requires the Secretary of Defense to enter into an agreement with a federally funded research and development center or an independent entity to conduct a study on force mix options and service models. 46 The options and models are to enhance the readiness of the medical force of the Armed Forces to deliver combat care on the battlefield, and assist public health responses to pandemics or other national public health emergencies. The section also requires the Secretary of Defense to submit a report to the House and Senate Armed Services Committees on the findings and recommendations resulting from the study. 47 DOD entered into an agreement with a research and development center, consistent with the requirement. However, DOD had not submitted the report to appropriate congressional committees as of April 2023. According to DOD officials, the department was reviewing a draft report internally at that time. Officials noted it was a priority to provide it to Congress as soon as possible. MTF Care DOD has completed actions to address nearly 94 percent of the requirements (15 of 16) related to MTF care and has taken actions to partially address approximately 6 percent (one of 16), as shown in figure 6. 45See GAO-23-106094, when available. 46William M. (Mac) Thornberry NDAA for Fiscal Year 2021, Pub. L. No. 116-283, § 757 (2021). 47This report was due not later than 15 months after the enactment of the NDAA (i.e., not later than 15 months from January 1, 2021). Page 26 GAO-23-105710 Defense Health Care Figure 6: Status of DOD's Actions to Address National Defense Authorization Acts for Fiscal Years 2012-2022 Requirements Related to Military Medical Treatment Facility Care The requirement that DOD has partially addressed is found in section 726 of the NDAA for Fiscal Year 2017, which requires the Secretary of Defense to implement a program to eliminate variability of care at MTFs. 48 As part of the program, DOD is required to develop, implement, monitor, and update clinical practice guidelines, which are evidence-based recommendations intended to help providers improve the consistency and quality of care in determining the best treatment options for a particular disease or condition. DOD has partially addressed this requirement because it has not implemented a process to systematically monitor the use of its clinical practice guidelines. DOD and the Department of Veterans Affairs began jointly developing and implementing clinical practice guidelines in 1998, and as of April 2023, they had jointly developed 22 of them. These guidelines address specific health conditions, including those related to chronic diseases, mental health issues, pain management, and rehabilitation. Providers at MTFs and Veterans Affairs medical centers may refer to these guidelines when determining the best course of treatment for their patients. However, providers are not required to use the guidelines. In February 2021, we reported that DHA and the military services are not systematically monitoring MTFs' implementation of these guidelines. 49 For example, while the Army tracks education and training on the clinical practice guidelines at its MTFs, officials with DHA, the Navy, and the Air Force explained that they have not been monitoring MTF implementation. We reported that DHA officials agreed that they need to develop a 48Pub. L. No. 114-328, § 726 (2016). 49GAO, DOD Health Care: DOD Should Monitor Implementation of Its Clinical Practice Guidelines, GAO-21-237 (Washington, D.C.: Feb. 5, 2021). Page 27 GAO-23-105710 Defense Health Care monitoring process as they assume administrative and oversight responsibilities for the military services' MTFs, but had not developed a plan to do so at the time of our prior review. As a result, we recommended that the Director of DHA collaborate with the Surgeons General of the military services to develop and implement a process to monitor the implementation of clinical practice guidelines. DOD concurred with our recommendation, and in February 2023, the department provided an updated plan to implement it with an anticipated completion date of March 2024. Private-Sector Care DOD has completed actions to address approximately 77 percent of the requirements (37 of 48) related to private-sector care and has taken actions to partially address nearly 21 percent (10 of 48). Finally, it has not taken actions to address approximately 2 percent (one of 48), as shown in figure 7. Figure 7: Status of DOD's Actions to Address Fiscal Year 2012-2022 National Defense Authorization Act Requirements Related to Private-Sector Care Note: We identified four requirements in the Private-Sector Care category that were within our scope of reforms but for which we were unable to determine the extent to which DOD addressed them because, for example, the information that DOD was required to post online was no longer available. We do not include these requirements in our counts of DOD's actions. The 11 partially and not-addressed requirements are found in four NDAA sections and relate to the (1) TRICARE Select implementation plan, (2) TRICARE contract acquisition strategy, (3) implementation of value- based care initiatives, and (4) core quality performance metrics. TRICARE Select implementation plan. Section 701 of the NDAA for FY 2017 requires DOD to establish a new preferred provider network health plan option called TRICARE Select. 50 It also requires DOD to develop a 50Pub. L. No. 114-328, § 701(a) (2016), codified as amended at 10 U.S.C. § 1075. Page 28 GAO-23-105710 Defense Health Care related implementation plan that addresses specific elements that target issues such as access to care, beneficiary complaints, and quality metrics for network providers. DOD took actions to partially implement the requirement for this implementation plan because it has not fully addressed one of the implementation plan's elements. In April 2018, we reported on DOD's implementation plan for TRICARE Select. 51 We found that DOD was in the process of developing its approach for the element related to defining access standards when it submitted the plan. As a result, the implementation plan does not include current information about how access standards will be established for this benefit option. We recommended that DOD provide Congress written documentation of its approach for developing and approving access standards, as well as the final access standards. DOD agreed with our recommendation, but as of April 2023, had not taken action to address it. TRICARE contract acquisition strategy. Section 705 of the NDAA for Fiscal Year 2017 requires DOD to develop an acquisition strategy for its TRICARE managed care support contracts that includes 13 specific elements, including actions related to provider networks; telehealth; value-based methodologies; and access to care in rural, remote, and isolated areas. 52 DOD took actions to partially address four requirements related to this section. In February 2020, we reported that DOD had partially implemented six of the 13 elements in its T-2017 (fourth generation) managed care support contracts, as shown in figure 8. 53 51GAO, Defense Health Care: TRICARE Select Implementation Plan Included Mandated Elements, but Access Standards Should Be Clarified, GAO-18-358 (Washington, D.C.: April 13, 2018). 52Pub. L. No. 114-328, § 705(c) (2016). 53GAO, Defense Health Care: Plans Needed to Ensure Implementation of Required Elements for TRICARE's Managed Care Support Contracts, GAO-20-197 (Washington, D.C.: Feb. 7, 2020). Page 29 GAO-23-105710 Defense Health Care Figure 8: Elements of Section 705(c) of the National Defense Authorization Act (NDAA) for Fiscal Year 2017 Implemented by DOD in the T-2017 Contracts, as of January 2020 At that time, DOD leadership explained that they decided to implement each of the 13 elements separately rather than developing a single strategy that addressed all of the elements. We further reported that DOD lacked plans with specific time frames and actions needed to fully implement all of the elements, and we recommended that DOD develop and implement plans with time frames and specific actions needed for all 13 required elements to be reflected in the TRICARE contracts. DOD concurred with our recommendation and implemented it by providing a planning document that contained the actions and time frames the department will use to guide its implementation of all 13 required elements. 54 DOD estimates that all of the 13 elements will be implemented by January 2026. 54In October 2020, DOD reported that achievement of the 13 elements in section 705(c) of the National Defense Authorization Act for Fiscal Year 2017 relies on demonstrations and pilots in the T-2017 contracts, rulemaking, and the development of new contract requirements for T-5 (the fifth generation of TRICARE contracts). Page 30 GAO-23-105710 Defense Health Care Implementation of value-based care initiatives. Sections 701, 705, and 729 of the NDAA for Fiscal Year 2017 collectively direct DOD to implement value-based care initiatives in TRICARE for civilian providers. This includes initiatives such as with programs that link payment with improved performance, as well as value-based initiatives for beneficiaries, such as with incentive programs that encourage a healthy lifestyle. 55 Value-based health care seeks to reward value over volume, with value generally measured in terms of improved health outcomes, enhanced experience of care for the patient, and reduced health care costs over time. DOD took actions to partially address three requirements related to these sections and has not taken actions to address one requirement. In September 2020, we reported on all of the value-based initiatives the department had identified, as well as the status of each initiative. 56 We consider these three requirements to be partially addressed because the department is piloting value-based initiatives in its T-2017 (fourth generation) contracts with the intent to more fully implement this methodology in its T-5 (fifth generation) contracts, as we reported in February 2020. 57 DOD awarded the fifth generation contracts in December 2022 with a health care delivery start date in 2024. 58 The T-5 request for proposal includes both short term and long term value-based initiatives. However, we cannot determine the implementation status of these initiatives until health care delivery is underway. Additionally, as of March 2023, DOD had not completed actions to address one requirement in section 701 for the department to provide a report to Congress on its efforts to implement value-based initiatives by January 1, 2023. Officials informed us in April 2023 that the report is going through internal review. This is the final report according to the requirements we reviewed. DOD has previously provided three reports to 55Pub. L. No. 114-328, §§ 701(h), 705, 729 (2016). 56GAO,Defense Health Care: Implementation of Value-Based Initiatives in TRICARE, GAO-20-695R (Washington, D.C.: Sept. 17, 2020). 57GAO-20-197. 58As of June 2023, there is a pending bid protest regarding the award of the TRICARE West region contract. Page 31 GAO-23-105710 Defense Health Care the House and Senate Armed Services Committees as required on its implementation of value-based initiatives. 59 Core quality performance metrics. Section 728 of the NDAA for Fiscal Year 2017 requires DOD to adopt, to the extent appropriate, certain core quality performance metrics for specific types of health care providers (e.g., accountable care organizations, patient centered medical homes, and primary care) as well as for specific specialties (e.g., gastroenterology, obstetrics and gynecology). 60 DOD took actions to partially address two requirements related to this section. Specifically, DHA has developed the core quality metrics, but we consider these requirements to be partially addressed because DHA officials told us they are waiting until health care delivery begins under the T-5 contracts to publish the metrics online. Training and Readiness DOD has completed actions to address approximately 63 percent of the requirements (25 of 40) related to training and readiness and has taken action to partially address nearly 38 percent (15 of 40), as shown in figure 9. Figure 9: Status of DOD's Actions to Address National Defense Authorization Acts for Fiscal Years 2012-2022 Requirements Related to Training and Readiness 59Department of Defense, Report to Congressional Defense Committees on Pilot Program on Incentive Programs to Improve Health Care Provided Under the TRICARE Program (Jan. 11, 2018); Report to the Armed Services Committees on Pilot Program on Incorporation of Value-Based Health Care in Purchased Care Component of TRICARE Program (Jan. 31, 2018); and Report to Congressional Defense Committees: Pilot Program on Incentive Programs to Improve Health Care Provided under the TRICARE Program (Feb. 18, 2020). The report on the incorporation of value-based health care addressed two requirements included in section 701(h)(3) and section 705(d) of the NDAA for Fiscal Year 2017. 60Pub. L. No. 114-328, § 728 (2016). Page 32 GAO-23-105710 Defense Health Care The 15 requirements that DOD has partially addressed are found in two NDAA sections and relate to (1) military-civilian integrated health delivery systems, and (2) efforts to maintain clinical wartime medical readiness skills and core competencies. Military-civilian integrated health delivery systems. Section 706 of the NDAA for Fiscal Year 2017 requires the Secretary of Defense to establish military-civilian integrated health delivery systems through partnerships with other health systems, including local or regional health systems in the private sector. 61 DOD took actions to partially address 14 requirements from section 706. In DOD's September 2022 report to Congress regarding these systems, submitted in response to section 743, the department stated that no contracts between MTFs and local civilian health care systems exist outside of TRICARE contracts. 62 DOD further stated in the report that their TRICARE contracts are how they establish an integrated military- civilian health delivery system. We found that DOD is partially addressing this reform through its TRICARE contracts. Specifically, DOD incorporated some of the required elements of section 706 into its solicitation for the T-5 contracts, such as through explicit requirements related to its civilian provider network. 61Pub. L. No. 114-328, § 706 (2016). A related section, section 743 of the NDAA for Fiscal Year 2020, requires the Secretary of Defense to conduct a study on the use of local military-civilian integrated health delivery systems pursuant to section 706 of the NDAA for Fiscal Year 2017 and develop a plan for the further development of the use of those systems. Pub. L. No. 116-92, § 743 (2019). DOD addressed section 743 by completing the study and submitting a report to the House and Senate Armed Services Committees in September 2022. See Department of Defense, Report to Congress, Section 743 of the National Defense Authorization Act for Fiscal Year 2020 (Public Law 116-92), Study and Plan on the Use of Military-Civilian Integrated Health Delivery Systems (Sept. 21, 2022). Sections 706 and 743 include requirements related to private-sector care as well as requirements related to training and readiness. We assigned both sections to the Training and Readiness category because some requirements pertain to maintenance of operational medical force readiness skills of health care providers of the Department and to providing members of the Armed Forces with additional training opportunities to maintain such readiness skills. 62Department of Defense, Report to Congress, Section 743 of the National Defense Authorization Act for Fiscal Year 2020 (Public Law 116-92), Study and Plan on the Use of Military-Civilian Integrated Health Delivery Systems (Sept. 21, 2022). DOD contracts with private-sector companies-referred to as managed care support contractors-to deliver health care services to its TRICARE program beneficiaries through networks of civilian providers. Page 33 GAO-23-105710 Defense Health Care Additionally, as outlined in its T-5 solicitation, DOD cites the potential use of its demonstration authority to compete for additional contracts within the managed care support contractor's geographic area of responsibility to provide beneficiaries with options for local and regional providers. According to DOD, demonstration projects will allow DHA to test the efficacy of having local and regional contracts that balance the need for accessible, high quality care for TRICARE beneficiaries with a need for hospital based readiness platforms for its medical personnel. We consider the related requirements for this section to be partially addressed because health care delivery under the T-5 contracts is scheduled to begin in 2024, and we cannot determine the implementation status of these initiatives until health care delivery is underway. Outside of TRICARE contracts, DOD's September 2022 report on sections 743 and 706 described four other types of partnerships with local civilian health care facilities in proximity to 49 military installations. According to DOD's report, (1) Memorandums of Understanding, (2) Training Affiliation Agreements, and (3) Medical Training Agreements expand services of the MTF or allow health care providers and students to attain critical wartime readiness skills and training by providing hands- on experience that is not seen on a regular basis in the direct care system. The report further discusses a fourth partnership type––External Resource Sharing Agreements. These written agreements between TRICARE contractors, the MTF, and a TRICARE network facility assist MTFs in providing staff augmentation due to difficulties in filling open positions or personnel shortages to meet a given demand or in support of an MTF contingency. Measures to maintain critical wartime medical readiness skills and core competencies. Section 725 of the NDAA for Fiscal Year 2017 requires the Secretary of Defense to implement measures to maintain the critical wartime medical readiness skills and core competencies of health care providers within the Armed Forces. 63 DOD took actions to partially address one requirement related to this section. We reported in February 2019, that DOD had begun several initiatives related to section 725, such as developing policy, involving leaders, and realigning governance structures. 64 However, we reported that the department's methodology for assessing the clinical readiness of its providers was limited and 63Pub. L. No. 114-328, § 725 (2016). 64GAO-19-206. Page 34 GAO-23-105710 Defense Health Care recommended improvements with which the department concurred but had not fully implemented as of April 2023. Specifically, we recommended that DOD identify and mitigate limitations in the clinical readiness metric and prioritize critical wartime specialties to which the clinical readiness metric could be expanded. We also recommended that it estimate the cost and benefits, by specialty, of implementing a clinical readiness metric and use that information to determine whether it should revise its approach. According to its latest plan to implement these recommendations, DOD expects to finish its framework for expanding the readiness metric by June 2023. Likewise, DOD estimates completing the other recommendations by the end of fiscal year 2025 by publishing guidance and improving data collection and analysis in connection with the reliability of the metric. MHS components maintain processes to identify and delegate DOD Does Not responsibility for addressing requirements for reform found in annual Systematically or NDAAs, and DOD maintains a process for identifying and tracking requirements for reports and briefings to Congress. However, the Office Comprehensively of the Assistant Secretary of Defense for Health Affairs' monitoring of Monitor Actions Taken actions taken to address requirements for reform is not systematic or comprehensive. in Response to Requirements for MHS Reform MHS Components MHS components-including the Office of the Assistant Secretary of Maintain Processes to Defense for Health Affairs (hereafter referred to as Health Affairs), DHA, and the military departments' medical headquarters-maintain similar Delegate Requirements processes for identifying and delegating responsibilities for MHS reform for MHS Reform and requirements included in the annual NDAA. For example, a Health Affairs Identify and Track official explained that Health Affairs' Congressional Affairs office tracks Reporting Requirements NDAA bills throughout their development until enactment, identifying potential requirements for reform and officials responsible for affected MHS functions. For each NDAA enacted, the Congressional Affairs office delegates responsibility for implementing reform requirements to the Page 35 GAO-23-105710 Defense Health Care appropriate officials in Health Affairs and DHA. 65 The official also explained that the Congressional Affairs office coordinates with the military departments regarding requirements where coordination may be needed between the Health Affairs, DHA, and the military department medical headquarters to implement. Likewise, officials from each of the military departments' medical organizations stated that their respective offices of legislative affairs, as well as their services' headquarters-level offices of legislative affairs, track the annual NDAA through the legislative process to identify potential reform requirements. This includes both those that their respective department must lead, and those for which it will not have lead responsibilities but must provide input. Military department officials stated that their respective offices of the Assistant Secretary of the Army, the Navy, or the Air Force for Manpower and Reserve Affairs typically receive requests for input from other DOD components (e.g., Health Affairs, Office of the Under Secretary of Defense for Acquisition and Sustainment) regarding requirements for each enacted NDAA. According to officials, upon receiving the requests, these military department offices task their subordinate organizations, including the Surgeons General and medical headquarters, with implementing actions to address requirements. 66 Officials stated that their Surgeons General or respective medical headquarters then task the appropriate offices and subject matter experts with executing their role in implementing the requirement. 65The official explained that the Congressional Affairs office may identify MHS reform requirements for which Health Affairs and DHA are not responsible; in these cases, the Congressional Affairs office identifies and communicates with the appropriate element (e.g., the Office of the Under Secretary of Defense for Acquisition and Sustainment, Policy, or Personnel and Readiness) about the requirement. 66Officials explained that this is a consequence of most reform requirements being directed to the Secretary of Defense or DHA. They stated that, for requirements enacted into law that are directed exclusively to the military departments, formal delegations within the military departments are sent to their respective surgeons general, which will then task the appropriate offices and individuals with implementing the requirements. Page 36 GAO-23-105710 Defense Health Care DOD-Wide Process to Report to Congress DOD also maintains a process for identifying and tracking reports and Has Limitations briefings to congressional recipients. Specifically, officials from the Office We reported in February 2022 on challenges of the Assistant Secretary of Defense for Legislative Affairs (Legislative with the DOD-wide process for responding to congressional reporting requirements. We Affairs) review the NDAA to identify reporting requirements for DOD. found that DOD officials sometimes Legislative Affairs officials then assign reporting requirements to the independently assigned and tracked their appropriate DOD components (e.g., military departments, defense reporting requirements using separate systems, and that DOD had limited agencies) through a central database. As DOD components prepare performance data on its process, among other reports and briefings in response to congressional reporting challenges. requirements, they provide Legislative Affairs with status updates. We recommended that DOD modernize this process by ensuring responsible officials in According to officials from Health Affairs and DHA, Legislative Affairs the Office of the Secretary of Defense consult officials provide them and other DOD components with assistance, as with internal stakeholders, establish performance measures, and collect the necessary, and track the status of reporting requirements. After DOD necessary data to assess progress towards components complete a draft report in response to a congressional goals. DOD concurred. As of April 2023, DOD reporting requirement, the report is coordinated within DOD for review had not yet implemented the recommendations. and signature, and an electronic copy is uploaded to the Legislative Source: GAO-22-105183. | GAO-23-105710 Affairs database. In February 2022, we reported on and made recommendations related to the limitations with DOD's congressional reporting process (see sidebar). 67 Health Affairs Monitoring Health Affairs is charged with carrying out management oversight of the of Actions Taken to MHS and directing changes in the execution of health-related matters across DOD, which it executes at a strategic level. Specifically, Health Address Requirements for Affairs conducts high-level monitoring of efforts to address some MHS Reform Is Not Systematic reform requirements, including participation in MHS governance forums or Comprehensive and ad hoc working groups. For example, Health Affairs participates in the following MHS governance forums: • The Military Health System Executive Review, which is a senior- level forum for DOD leadership to help maintain focus on MHS interrelated issues-including responding to statutory mandates and other congressional special interests-and implementing MHS governance reforms. 68 • The Senior Military Medical Advisory Council, which is the executive-level forum for establishing comparability, consistency, and 67GAO, Defense Management: DOD Should Collect More Stakeholder Input and Performance Data on Its Congressional Reporting Process, GAO-22-105183 (Washington, D.C.: Feb. 10, 2022). 68A draft update to the charter of the Military Health System Executive Review Board states that the Board will ensure implementation of NDAA and other legal requirements. However, a Health Affairs official explained that the Board will continue to focus on the subset of statutory requirements that involve multiple MHS components. Page 37 GAO-23-105710 Defense Health Care standardization, and providing the Assistant Secretary of Defense for Health Affairs with advice on executing his or her responsibilities. • The Deputy Military Medical Action Council, which is the governance body through which Health Affairs performs oversight of the system, monitors the performance of the MHS, and provides decision support to the Assistant Secretary of Defense for Health Affairs through the Senior Military Medical Advisory Council. Health Affairs also participates in the execution and monitoring of reform requirements on a limited basis. For example, according to a charter signed in September 2017, the Acting Assistant Secretary of Defense for Health Affairs established a temporary Program Management Office to plan and track the MHS components' efforts to address reform requirements from the NDAA for Fiscal Year 2017. Health Affairs officials also participated in various working groups that conducted implementation planning for specific sections of the NDAA. The Program Management Office disbanded in May 2018 after it determined that the MHS components had addressed requirements, or handed off responsibilities for continuing implementation oversight to a responsible component. However, we found that several requirements from the NDAA for Fiscal Year 2017-such sections 706 and 721-were partially addressed. The MHS governance forums and ad hoc Program Management Office and working groups do not provide Health Affairs with a systematic or comprehensive view of MHS reform efforts. In addition, these groups do not provide Health Affairs with a mechanism for ensuring accountability of reform implementation. For example, the governance forums provide an opportunity for various levels of MHS leadership to discuss, among other things, achievement of strategic priorities and key reform efforts. However, according to a Health Affairs official, it is not within the scope of their responsibilities to actively monitor the universe of MHS reform efforts. Furthermore, with respect to ad hoc working groups, a Health Affairs official we interviewed stated that Health Affairs participates in these efforts when the implementation of a reform requirement necessitates multiple components' involvement, but generally delegates execution and monitoring of requirements to MHS components. The department has also reported on the limitations of monitoring and executing MHS reforms through a working group construct. Specifically, in an August 2022 report on medical headquarters manpower requirements, a DOD study team concluded that they should replace the Page 38 GAO-23-105710 Defense Health Care working group structure of implementation and monitoring with a more permanent structure in the future. 69 DOD Directive 5136.01 states that Health Affairs provides oversight to the DOD components on matters pertaining to the MHS, and oversees and directs changes in the execution of health-related matters across the DOD. 70 To carry out its oversight responsibilities, among other things, the Assistant Secretary of Defense for Health Affairs is responsible for developing and managing an MHS-wide strategic management program and organizational improvement measures that demonstrate value across the MHS enterprise. The Assistant Secretary also ensures the DOD components of the MHS are attentive and responsive to the requirements of their organizational customers, both internal and external to DOD. Furthermore, Standards for Internal Control in the Federal Government state that management should use quality information and should design control activities to achieve objectives, such as by clearly documenting significant actions in a manner that allows the documentation to be readily available for examination. 71 Applied to Health Affairs in its oversight responsibilities, this internal control principle would include monitoring the implementation actions related to legislative requirements for MHS reform. Health Affairs has not monitored the full scope of reform implementation by the MHS components because it has not established a process to do so––such as by consolidating in a single data source the responsible leaders, actions taken, and time frames. In the absence of a process for monitoring actions taken to address all requirements, Health Affairs did not have information about the implementation status of certain requirements. For example, Health Affairs did not have information on the actions taken to develop a strategic sourcing acquisition strategy for health care professional staff in response to section 727 of the NDAA for Fiscal Year 2017. Health Affairs officials provided us with contacts in DHA's Contracting Activity to discuss these actions. Similarly, Health Affairs did not have information on actions to address section 706 of the NDAA for Fiscal Year 2017 and could not provide a contact in another 69Under Secretary of Defense for Personnel & Readiness, Zero-Based Review of Medical Headquarters Manpower Requirements (August 2022). 70DOD Directive 5136.01. 71GAO, Standards for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: Sept. 10, 2014). Page 39 GAO-23-105710 Defense Health Care MHS component who could discuss actions to implement this section. A DOD report to Congress from September 2022 on the use of local military-civilian integrated health delivery systems provided some information on DOD's actions to address section 706, as described previously. 72 However, DHA was not able to identify subject matter experts to discuss questions about this report or the future implementation plans the report described. Establishing a monitoring process could provide complete information on MHS reforms for Health Affairs to use in performing monitoring efforts. Health Affairs sets some strategic priorities and monitors some performance measures to assess progress in achieving MHS goals. 73 Officials stated they review these measures quarterly and brief the results to MHS governance bodies and the Deputy Secretary of Defense. A Health Affairs official also stated that Health Affairs recently started performing ad hoc root cause analyses when they identify negative trends in these performance measures, and added that these analyses sometimes allow them to identify the effects of reform efforts. A monitoring process for MHS reform requirements would strengthen Health Affairs' ability to investigate fluctuations in MHS performance by enhancing awareness of changes within the system that could drive performance trends. MHS components-especially DHA-have made substantial progress in taking actions to address MHS reform requirements, as evidenced by the number of reforms addressed; however, many of the partially addressed reforms have large scopes. Establishing a systematic process to comprehensively monitor implementation actions would better position Health Affairs to have visibility over the full scope of MHS components' efforts to address reform requirements. Such visibility could help Health Affairs provide effective oversight of these multi-year initiatives that relate to the MHS goals of better health, better care, improved readiness, and lower costs. Furthermore, without sustained monitoring to improve oversight, the length of major transformations, which can span several 72Section 743 of the NDAA for Fiscal Year 2020 requires the Secretary of Defense to conduct a study on the use of local military-civilian integrated health delivery systems pursuant to section 706 of the NDAA for Fiscal Year 2017 and develop a plan for the further development of the use of those systems. Pub. L. No. 116-92, § 743 (2019). DOD addressed section 743 by completing the study and submitting a report to the House and Senate Armed Services Committees in September 2022. 73Health Affairs officials stated that 17 of 27 of these performance measures are complete and in use, and another five will become available when DOD completes implementation of its new electronic health record, MHS Genesis. Page 40 GAO-23-105710 Defense Health Care years, coupled with interim leadership changes across administrations could place DOD at risk of reform requirements losing momentum and not being completed. DOD has made significant progress in addressing reforms included in the Conclusions annual NDAAs from fiscal year 2012 through fiscal year 2022-taking actions to address 115 of the 158 (approximately 73 percent) of requirements. However, additional actions remain to address the remaining requirements. Specifically: • DOD has not provided a briefing to the House and Senate Armed Services Committees regarding the closure of inpatient capabilities at Aviano Air Force Base's MTF, despite a statutory requirement that it do so prior to eliminating inpatient capabilities. By providing this information, DOD will facilitate Congress's ability to execute oversight of actions to restructure MHS facilities. • DOD has not completed the transfer of public health and research and development functions from the military departments to DHA. By completing implementation plans with time frames to address these requirements, DOD will improve the likelihood that efforts to complete these two transfers-which were supposed to have been completed by the end of fiscal year 2022-do not stagnate. • Health Affairs has set strategic priorities and monitors a set of performance measures in order to evaluate MHS outcomes. It also performs ad hoc analyses in response to negative performance trends. By establishing a process to comprehensively monitor the actions taken and remaining to address statutory requirements for the military health system, Health Affairs will be better positioned to oversee the full scope of efforts to address reform requirements, including multi-year initiatives that relate to the MHS goals of better health, better care, improved readiness, and lower costs. Furthermore, without sustained monitoring to improve oversight, the length of major transformations––which can span several years–– coupled with interim leadership changes across administrations, could put DOD at risk of reform requirements losing momentum and not being completed. Completing these reforms and monitoring the full scope of these and other statutory MHS reform efforts will better position DOD to ensure it is achieving its goals for better health, better care, improved readiness, and lower costs. Page 41 GAO-23-105710 Defense Health Care We are making the following four recommendations to DOD: Recommendations for Executive Action The Secretary of Defense should ensure that the Secretary of the Air Force, in coordination with the Surgeon General of the Air Force and the Director of the DHA, completes a briefing to the House and Senate Armed Services Committees regarding the previous elimination of inpatient capabilities from its MTF at Aviano Air Force Base. (Recommendation 1) The Secretary of Defense should ensure that the Director of the DHA, in coordination with the Surgeons General of the military departments, completes an implementation plan with related timelines for the remaining phases of the public health transfer and provides the plan to Congress. (Recommendation 2) The Secretary of Defense should ensure that the Director of the DHA, in coordination with the Surgeons General of the military departments, completes an implementation plan with related timelines for the transfer of research and development, and provides the plan to Congress. (Recommendation 3) The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs establishes a systematic process to comprehensively monitor the actions taken to address statutory requirements for the MHS, and incorporates the information in its MHS evaluation activities. The process could include consolidating in a single data source the responsible leaders, actions taken, and time frames. (Recommendation 4) We provided a draft of this report to DOD for review and comment. DOD Agency Comments provided an official comment letter, reproduced in appendix IV, which concurred with each of the four recommendations. DOD also provided technical comments that we incorporated where appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretary of Defense, the Assistant Secretary of Defense for Health Affairs, and the Secretaries of the Army, the Navy, and the Air Force. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. Page 42 GAO-23-105710 Defense Health Care 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 major contributions to this report are listed in appendix V. Brenda S. Farrell Director, Defense Capabilities and Management Page 43 GAO-23-105710 Defense Health Care Appendix I: Prior GAO Reports Related to Appendix I: Prior GAO Reports Related to Military Health System Reform and Military Health System Reform and Recommendation Status Recommendation Status Table 2: GAO Reports Related to Military Health System (MHS) Reform and Recommendations Status, As of April 2023 Corresponding MHS GAO report reform requirements Recommendation status GAO-12-911 National Defense We recommended that the Department of Defense (DOD) Defense Health Care: Additional Analysis Authorization Act develop (1) a comprehensive cost analysis for its potential MHS of Costs and Benefits of Potential (NDAA) for Fiscal Year governance structures, (2) a business case analysis and strategy Governance Structures Is Needed 2012, Section 716 for implementing its shared services concept, and (3) more (September 2012) complete analyses of the options' strengths and weaknesses. • DOD implemented the second recommendation. • DOD did not concur with the other two recommendations. We closed them as not implemented. GAO-12-224 NDAA for Fiscal Year We recommended that DOD (1) complete and fully implement Defense Health Care: Applying Key 2012, Section 716 comprehensive results-oriented plans for each of its medical Management Practices Should Help initiatives; (2) fully implement an overall monitoring process Achieve Efficiencies within the Military across the portfolio of initiatives and identify accountable officials Health System (April 2012) and their roles and responsibilities; and (3) complete its governance initiatives and employ key management practices to show financial and nonfinancial outcomes and evaluate interim and long-term progress. • DOD concurred with the first recommendation, and stated in 2015 that it established a consolidated strategic plan to address the recommendation; however, the plan was not published. Given the lack of action on DOD's part, in July 2017, we closed the recommendation as not implemented. • DOD implemented the other two recommendations. GAO-14-49 NDAA for Fiscal Year We recommended DOD develop and present to Congress fully Defense Health Care Reform: Additional 2013, Section 731 developed performance measures related to the newly created Implementation Details Would Increase Defense Health Agency, interim timelines, staffing baseline Transparency of DOD's Plans and assessments, and refined cost savings estimates. Enhance Accountability (November • DOD concurred with the recommendation regarding 2013) timelines but did not develop the timelines. In June 2017, we closed the recommendation as not implemented because the Defense Health Agency was fully implemented, therefore, timelines to show progress were no longer relevant. • DOD implemented the other four recommendations. GAO-14-396T NDAA for Fiscal Year There are no recommendations associated with this report. Military Health System: Sustained Senior 2013, Section 731 Leadership Needed to Fully Develop Plans for Achieving Cost Savings (February 2014) GAO-15-759 NDAA for Fiscal Year We made five recommendations related to the Defense Health Defense Health Care Reform: Actions 2013, Section 731 Agency's personnel requirements and approach to achieving cost Needed to Help Ensure Defense Health savings. Agency Maintains Implementation • DOD implemented all of the recommendations. Progress (September 2015) Page 44 GAO-23-105710 Defense Health Care Appendix I: Prior GAO Reports Related to Military Health System Reform and Recommendation Status Corresponding MHS GAO report reform requirements Recommendation status GAO-16-820 Carl Levin and Howard We recommended that DOD (1) conduct a new analysis of the Defense Health Care Reform: DOD P. "Buck" McKeon required number of active-duty and civilian medical personnel Needs Further Analysis of the Size, NDAA for Fiscal Year that mitigates known limitations; (2) identify and mitigate Readiness, and Efficiency of the Medical 2015, Section 713 limitations regarding the standard for maintaining providers' Force (September 2016) clinical skills; (3) develop a strategy for achieving its goals for transferring health care to DOD facilities and increasing the productivity of active-duty providers; (4) modify its provider model to reflect the military service of the physicians and military treatment facilities included in the model; and, when considering proposed changes to facilities, (5) describe steps taken to assess the reliability of data supporting the assessment, and (6) include in any accompanying cost estimates an appropriate level of detail. • DOD concurred with all six recommendations and they remain open (that is, not implemented). GAO-17-791R NDAA for Fiscal Year There are no recommendations associated with this report. Defense Health Reform: Steps Taken to 2017, Section 702 Plan the Transfer of the Administration of the Military Treatment Facilities to the Defense Health Agency, but Work Remains to Finalize the Plan (September 2017) GAO-18-108R NDAA for Fiscal Year There are no recommendations associated with this report. Department of Defense: Telehealth Use 2017, Section 718 in Fiscal Year 2016 (November 2017) GAO-18-300 NDAA for Fiscal Year We recommended DOD incorporate leading practices in its New Trauma Care System: DOD Should 2017, Section 707 planning to guide implementation efforts. Fully Incorporate Leading Practices into • DOD implemented this recommendation. Its Planning for Effective Implementation (March 2018) GAO-18-361 NDAA for Fiscal Year There are no recommendations associated with this report. Defense Health Care: TRICARE Surveys 2012, section 721 Indicate Nonenrolled Beneficiaries' NDAA for Fiscal Year Access to Care Has Generally Improved 2017, Section 701 (March 2018) GAO-18-358 NDAA for Fiscal Year We recommended DOD provide written documentation of its Defense Health Care: TRICARE Select 2017, Section 701 approach for developing and approving the TRICARE Select Implementation Plan Included Mandated access standards, as well as the final access standards, to Elements, but Access Standards Should Congress. Be Clarified (April 2018) • DOD concurred with this recommendation and it remains open. Page 45 GAO-23-105710 Defense Health Care Appendix I: Prior GAO Reports Related to Military Health System Reform and Recommendation Status Corresponding MHS GAO report reform requirements Recommendation status GAO-18-574 NDAA for Fiscal Year We recommended that DOD (1) prioritize, as appropriate, Defense Health Care: Expanded Use of 2016, Section 730 selecting quality measures common for both direct and Quality Measures Could Enhance purchased care that expand the range of quality areas covered Oversight of Provider Performance by the measures and (2) establish consistent performance (September 2018) standards and corrective action requirements for direct and purchased care providers. • DOD concurred with both recommendations and they remain open. GAO-19-53 NDAA for Fiscal Year We recommended that DOD (1) define and analyze the 16 Defense Health Care: DOD Should 2017, Section 702 operational readiness and installation-specific medical functions Demonstrate How Its Plan to Transfer for duplication, (2) validate headquarters-level personnel the Administration of Military Treatment requirements, and (3) identify the least costly mix of personnel. Facilities Will Improve Efficiency • DOD concurred with these recommendations. It has partially (October 2018) addressed one recommendation and it remains open. The other two recommendations remain open. GAO-19-102 NDAA for Fiscal Year We made five recommendations including that DOD, among Defense Health Care: Additional 2017, Section 721 other things, (1) assess the suitability of federal civilians and Assessments Needed to Better Ensure contractors to provide operational medical care; (2) develop full an Efficient Total Workforce (November cost information for active and reserve component medical 2018) personnel; and (3) develop a strategic total workforce plan for the DHA to help ensure execution of an appropriate workforce mix at its Military Medical Treatment Facilities (MTFs). • DOD concurred with each recommendation and they remain open. GAO-19-206 NDAA for Fiscal Year We made six recommendations, including that DOD establish Defense Health Care: Actions Needed to 2017, Section 721 joint planning assumptions and a definition, as well as a method Determine the Required Size and NDAA for Fiscal Year for assessing medical and dental personnel requirements; Readiness of Operational Medical and 2017, Section 725 identify and mitigate limitations in a clinical readiness metric for Dental Forces (February 2019) medical providers; and determine specialties and estimate costs and benefits for applying a readiness metric. • DOD concurred with each recommendation and they remain open. GAO-19-338 NDAA for Fiscal Year There are no recommendations associated with this report. Defense Health Care: DOD's Proposed 2017, Section 749 Plan for Oversight of Graduate Medical Education Programs (March 2019) GAO-20-39 NDAA for Fiscal Year GAO made three recommendations to improve future contract Defense Health Care: Opportunities to 2017, Section 701 transitions, including that DOD improve the specificity of its Improve Future TRICARE Managed Care transition guidance and have subject matter experts review Support Contract Transitions (November oversight requirements. 2019) • DOD implemented all the recommendations. GAO-20-165 NDAA for Fiscal Year We recommended that DOD collect and use information on (1) Defense Health Care: DOD Should 2017, Section 708 replacement costs of military physicians and dentists, (2) Collect and Use Key Information to Make retention, and (3) private-sector civilian wages to inform its Decisions about Incentives for investment decisions. Physicians and Dentists (January 2020) • DOD concurred with these three recommendations and they remain open. Page 46 GAO-23-105710 Defense Health Care Appendix I: Prior GAO Reports Related to Military Health System Reform and Recommendation Status Corresponding MHS GAO report reform requirements Recommendation status GAO-20-197 NDAA for Fiscal Year We recommended that DOD develop and implement plans with Defense Health Care: Plans Needed to 2017, Section 705 time frames and specific actions needed for all 13 required Ensure Implementation of Required elements in the TRICARE contracts. Elements for TRICARE's Managed Care • DOD implemented this recommendation. Support Contracts (February 2020) GAO-20-371 NDAA for Fiscal Year We made six recommendations, including that future MTF Defense Health Care: Additional 2017, Section 703 assessments use more complete and accurate information about Information and Monitoring Needed to civilian health care quality, access, and cost-effectiveness; and Better Position DOD for Restructuring that DOD establish roles, responsibilities, and progress Medical Treatment Facilities (May 2020) thresholds for MTF transitions. • DOD partially concurred with four recommendations and concurred with two. All six recommendations remain open. GAO-21-237 NDAA for Fiscal Year We recommended that DHA work with the military services to DOD Health Care: DOD Should Monitor 2017, Section 726 develop and implement a systematic process to monitor MTFs' Implementation of Its Clinical Practice implementation of Veterans Affairs/DOD clinical practice Guidelines (February 2021) guidelines. • DOD concurred with this recommendation and it remains open. GAO-21-337 NDAA for Fiscal Year We made 30 recommendations, including that military Defense Health Care: Actions Needed to 2017, Section 725 departments fully define and implement wartime medical skills for Define and Sustain Wartime Medical enlisted medical personnel subspecialties, track skills training, Skills for Enlisted Personnel (June 2021) and establish performance goals and targets for training completion, as appropriate; and that DOD develop metrics to assess how military medical treatment facility workload and civilian partnerships sustain these skills and assess risks to skills sustainment. • DOD concurred with each of these recommendations and they remain open. GAO-22-104770 NDAA for Fiscal Year We recommended that DOD assess and monitor how providing Defense Health Care: Actions Needed to 2017, Section 717 civilian emergency care maintains medical readiness, issue Improve Billing and Collection of Debt for guidance to update systems with complete collection information, Civilian Emergency Care (July 2022) track and monitor waiver requests, and communicate financial relief options. • DOD did not provide comments on a draft of this report. These four recommendations remain open. GAO-22-105149 NDAA for Fiscal Year There are no recommendations associated with this report. Defense Health Care: DOD Expanded 2017, Section 718 Telehealth for Mental Health Care during the COVID-19 Pandemic (February 2022) Source: GAO. | GAO-23-105710 Note: To view the status and details of all GAO recommendations concerning the reports noted above, click on the respective report number provided in each row of the table. Page 47 GAO-23-105710 Defense Health Care Appendix II: Objectives, Scope, and Appendix II: Objectives, Scope, and Methodology Methodology Section 742 of the National Defense Authorization Act (NDAA) for Fiscal Year 2022 included a provision for us to report on the Department of Defense's (DOD) efforts to address statutory requirements to reform the Military Health System (MHS) from fiscal years 2012 through 2021. 1 We also included relevant statutory requirements from the NDAA for Fiscal Year 2022 as part of our analysis. In this report we examine, • statutory requirements for reforms of the MHS that GAO identified within each NDAA for Fiscal Years 2012 through 2022; • the extent to which DOD has taken actions to address these requirements and assessed the effectiveness of certain reforms as required, and • the extent to which DOD has monitored actions taken in response to statutory requirements for MHS reform. Objective One For objective one, we first developed a definition of MHS reform in order to identify statutory requirements for MHS reform. To accomplish this, we identified relevant Congressional and DOD sources on MHS reform during the in-scope time period. These sources include Senate Report 114-255, which accompanied a bill for the NDAA for Fiscal Year 2017 and outlines the reform objectives of the Senate Armed Services Committee, as well as specific provisions to accomplish these objectives. 2 Senate Report 114-255 also references the findings and recommendations of DOD's Military Compensation and Retirement Modernization Commission, which was formed to provide recommendations to modernize pay and benefits of the services and includes recommendations regarding the health benefits of service members and their dependents. DOD provided Congress with a report on the Commission's recommendations in January 2015, which we reviewed in order to identify language describing MHS reform activities. Based on the language identified in these sources, we defined MHS reform as enterprise changes affecting the population of beneficiaries, medical providers, and/or administrators (including leadership), or a significant portion thereof and that relate to one or more of the following goals: (1) improving the quality of beneficiary health care, (2) improving 1Pub. L. No. 117-81, § 742 (2021). 2S. Rep. No. 114-255, at 173-205 (2016). Page 48 GAO-23-105710 Defense Health Care Appendix II: Objectives, Scope, and Methodology the operational readiness of military medical providers, and (3) reducing the cost of the health system overall. We excluded electronic health records modernization from our definition of MHS reform because it was not discussed in the aforementioned sources and because we have a substantial body of work reporting on DOD's efforts in this area. 3 To ensure the appropriateness of our definition, we reviewed it with officials from MHS component organizations, including the Office of the Assistant Secretary of Defense for Health Affairs, the Defense Health Agency, and the military departments. The officials generally agreed and made suggestions that we incorporated as appropriate. Next, we reviewed Title VII's "Health Care Provisions," of each NDAA from Fiscal Years 2012 through 2022 to identify NDAA sections meeting our definition of MHS reform. We assigned each section into one of five categories of reform which we developed based on common issue areas in the NDAAs: Governance and Administration; Force Structure and End Strength; Military Medical Treatment Facility Care; Private-Sector Care; and Training and Readiness. In multiple cases, requirements for reform related to two or more of these categories. However, in order to avoid double counting of requirements when reporting results, we assigned each section to the category that the requirements in the section focused on most. After identifying and categorizing in-scope NDAA sections, within each of the five categories, we broke down each section we identified as an MHS reform into separate requirements based on actions that the department would need to take to address each particular reform. We considered provisions that require one or more components of DOD to take an action to be a requirement. Conversely, we did not consider the following types of provisions to be reform requirements: 1) provisions that provide discretion in taking action; 2) provisions that provide authority; 3) provisions that outline responsibilities; and 4) provisions that only prohibit or limit actions (without requiring DOD to take an action because of a prohibition or limitation). Finally, we grouped elements (i.e., any subsections, paragraphs, and subparagraphs) together into one 3See GAO, Electronic Health Records: Additional DOD Actions Could Improve Cost and Schedule Estimating for New System, GAO-22-104521 (Washington, D.C.: June 8, 2022); GAO, Defense Health Care: DOD Expects New IT System Capabilities to Improve Other Health Insurance Processing, GAO-22-105131 (Washington, D.C.: Mar. 29, 2022); and GAO, Electronic Health Records: DOD Has Made Progress in Implementing a New System, but Challenges Persist, GAO-21-571 (Washington, D.C.: Sept. 20, 2021). Page 49 GAO-23-105710 Defense Health Care Appendix II: Objectives, Scope, and Methodology requirement when they were inherently part of the same action. We excluded one section and its requirements that were repealed by a subsequent NDAA. 4 We reviewed our categorization approach and list of requirements with MHS component officials and they agreed without comment. For figure 1, which includes the categories of requirements and example requirements, we selected examples illustrative of the range of topic areas within each category. From among all the requirements identified, we also identified those that mandated DOD assess the effectiveness of actions taken in response to reform requirements. In order to identify these requirements, an analyst reviewed all statutory requirements identified above. A separate analyst also reviewed all statutory requirements and the determinations of the first analyst, and the two reconciled any discrepancies through discussion. Objective Two For objective two, to assess the extent to which DOD took actions to address statutory requirements for MHS reform and assessed the effectiveness of reform actions, we first analyzed publicly available information regarding DOD's actions to address in-scope reform requirements. We also reviewed our prior work that assessed DOD's efforts to meet select requirements. We collected additional documentation and conducted interviews with DOD offices involved in the execution of these requirements, as necessary. After reviewing the documentation collected for each statutory requirement, an analyst assessed each requirement as "Addressed," "Partially Addressed," or "Not Addressed." 5 "Addressed" means DOD completed actions to address the requirement. "Partially Addressed" means DOD has taken actions to address some, half, or most of the elements of a requirement, irrespective of whether DOD has completed its actions or plans additional actions to address the requirement. "Not 4Section 727 of the NDAA for Fiscal Year 2017 repealed section 725 of the NDAA for Fiscal Year 2015, which we originally determined to be within the scope of our review based on our definition of MHS reform. 5Inmaking these assessments, we identified four requirements in the Private-Sector Care category that were within our scope of MHS reforms but for which we were unable to determine the extent to which DOD addressed them. This occurred for various reasons, such as information that DOD was required to post online no longer being available. We note these requirements as appropriate in the report, but do not include them in our counts of DOD's actions. Page 50 GAO-23-105710 Defense Health Care Appendix II: Objectives, Scope, and Methodology Addressed" means DOD did not address any elements of the requirement or has no plans to begin addressing it. In those cases where we have made a recommendation(s) regarding a "Partially Addressed" or "Not Addressed" requirement and the recommendation(s) remain Open– Partially Addressed or Open–Unaddressed, we noted this in the report. In assessing DOD's actions to address statutory requirements for MHS reforms, we did not assess the quality of actions to address these requirements. 6 Furthermore, for requirements requiring the delivery of a written product or briefing to Congress (e.g., report, study, etc.), we did not assess the extent to which required elements were included in the product or briefing, but instead identified whether or not a report was provided. 7 For such requirements, we provide references to our prior work that examined reports for these elements, as applicable. After the analyst made a determination for each requirement, a separate team member also reviewed the supporting documentation and made an independent determination, and the team reconciled any differences through discussion. This analysis also included those requirements mandating that DOD assess the effectiveness of reform action(s), as identified in the second objective above. For all requirements, we assessed DOD's actions against the statutory requirements related to reform. In addition, for multiple requirements related to the establishment of new organizations within the MHS, we examined DOD's efforts against GAO-18-427, Government Reorganization: Key Questions to Assess Agency Reform Efforts, which states that successful reform efforts entail the development of an implementation plan with key milestones and deliverables, which can help an organization track implementation progress. 8 Objective Three For objective three, to assess DOD's oversight of actions to address statutory requirements related to MHS reform, we discussed with DOD officials their methods for monitoring the status of statutory requirements. In addition, we obtained documentation from various DOD offices about 6While we did not assess the quality of DOD's actions to address these requirements, we discuss various actions taken in response to reform requirements for illustrative purposes. 7While we did not assess the inclusion of individual elements of requirements in written products or briefings, we discuss some elements of requirements for written products or briefings in this report for illustrative purposes. 8GAO-18-427. Page 51 GAO-23-105710 Defense Health Care Appendix II: Objectives, Scope, and Methodology requirements that had been addressed. Specifically, we interviewed officials and collected documents from MHS components about their processes for identifying and delegating implementation of statutory requirements. We assessed DOD's efforts against Department of Defense Directive 5136.01, Assistant Secretary of Defense for Health Affairs (ASD(HA)), which states that the Assistant Secretary of Defense for Health Affairs provides oversight to the DOD components on matters pertaining to the MHS, and oversees and directs changes in the execution of health- related matters across the DOD. 9 We also determined that the 1) control activities and 2) information and communication components of Standards for Internal Control in the Federal Government were significant to this objective, along with the underlying principles that management should 1) design control activities and 2) use quality information to achieve the entity's objectives. To address objectives two and three, we also conducted interviews with officials from several organizations within DOD having key responsibilities concerning the MHS. These included the Office of the Assistant Secretary of Defense for Health Affairs; multiple offices within the Defense Health Agency; the Joint Staff Surgeon's Office; U.S. Army Medical Command; Navy Bureau of Medicine and Surgery; and U.S. Air Force's Office of the Surgeon General. We conducted this performance audit from January 2022 to June 2023 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. 9Department of Defense Directive 5136.01, Assistant Secretary of Defense for Health Affairs (ASD(HA)) (Sep. 30, 2013) (incorporating change 1, Aug. 10, 2017). Page 52 GAO-23-105710 Defense Health Care Appendix III: Military Health System Reform Appendix III: Military Health System Reform Requirements from Fiscal Years 2012 through Requirements from Fiscal Years 2012 2022 that DOD Completed Actions to Address through 2022 that DOD Completed Actions to Address From fiscal years 2012 through 2022, there were 158 requirements for reform to the Military Health System across 39 National Defense Authorization Act sections. The table below lists the 115 requirements that the Department of Defense has completed actions to address. Table 3: Military Health System Reform Requirements that DOD Completed Actions to Address, by Category Public NDAA Law NDAA Number of Related GAO fiscal yeara number NDAA section number and title subsection(s) requirements reports Category: Governance and administration 2012 112-81 Sec. 716, Review of the Administration of the (a)(2) 1 GAO-12-911 Military Health System 2013 112-239 Sec. 731, Plan For Reform of the (a) 1 GAO-14-49 & Administration of the Military Health System GAO-14-396T 2015 113-291 Sec. 713, Review of Military Health System (a)(2) 1 GAO-16-820 Modernization Study 2017 114-328 Sec. 702, Reform of Administration of the (a)(1), (c), (d)(1), 10 GAO-17-791R Defense Health Agency and Military Medical (e)(1)-(2) GAO-19-53 Treatment Facilities 2017 114-328 Sec. 703, Military Medical Treatment Facilities (a)(1), (c), (d)(1) 5 GAO-20-371 (as amended by FY21 NDAA Sec. 718)b 2017 114-328 Sec. 727, Acquisition Strategy for Health Care (a)(1), (b) 2 N/A Professional Staffing Services 2017 114-328 Sec. 730, Accountability for the Performance (a), (b), (c)(1) 2 N/A of The Military Health System of Certain Leaders Within The System 2018 115-91 Sec. 722, Selection of Military Commanders (a), (c) 1 N/A and Directors of Military Medical Treatment Facilities 2019 115-232 Sec. 711, Improvement of Administration of (a)(1)(D), (c)(1) 2 N/A the Defense Health Agency and Military Medical Treatment Facilities 2019 115-232 Sec. 712, Support by Military Healthcare (e)(1)(A), 3 GAO-23-105441 System of Medical Requirements of (e)(2)(A), (f) Combatant Commands (as amended by FY20 Sec. 712) Category: Force structure and end strength 2017 114-328 Sec. 721, Authority to Convert Military Medical (b) 1 GAO-19-206 and Dental Positions to Civilian Medical and Dental Positions 2020 116-92 Sec. 719, Limitation on the Realignment or (b)(2), (c) 4 GAO-19-206 Reduction of Military Medical Manning End Strength Page 53 GAO-23-105710 Defense Health Care Appendix III: Military Health System Reform Requirements from Fiscal Years 2012 through 2022 that DOD Completed Actions to Address Public NDAA Law NDAA Number of Related GAO fiscal yeara number NDAA section number and title subsection(s) requirements reports 2021 116-283 Sec. 757, Study on Force Mix Options and (a) 1 N/A Service Models to Enhance Readiness of Medical Force of the Armed Forces 2022 117-81 Sec. 731, Modifications and Reports Related (b)(2),c (b)(3)(A) 4 GAO-19-206 to Military Medical Manning and Medical Billets Category: Military medical treatment facility care 2017 114-328 Sec. 704, Access to Urgent and Primary Care (a) 1 N/A Under TRICARE Program 2017 114-328 Sec. 709, Standardized System for Scheduling (a)(1), (c)(1), (d), 9 N/A Medical Appointments at Military Treatment (e)(1), (f), (g)(1) Facilities 2017 114-328 Sec. 726, Program to Eliminate Variability in (a) 1 GAO-21-237 Health Outcomes and Improve Quality of Health Care Services Delivered in Military Medical Treatment Facilities 2021 116-283 Sec. 756, Study and Report on Increasing (a), (b) 2 N/A Telehealth Services Across Armed Forces 2022 117-81 Sec. 723, Digital Health Strategy of (a)(1), (b) 2 N/A Department of Defense Category: Private-sector care 2016 114-92 Sec. 725, Pilot Program on Urgent Care Under (a)(1)-(3), 4 N/A TRICARE Program (c)(1)-(2) 2016 114-92 Sec. 726, Pilot Program on Incentive (a), (d)(1)-(3) 3 N/A Programs to Improve Health Care Provided Under the TRICARE Program 2016 114-92 Sec. 730, Report On Plans To Improve (a) 1 GAO-18-574 Experience With and Eliminate Performance Variability of Health Care Provided by the Department of Defense 2017 114-328 Sec. 701, TRICARE Select and Other (a)(1), (b)(1), (c)- 9 GAO-20-695R TRICARE Reform (d), (h)(1)-(3) 2017 114-328 Sec. 704, Access to Urgent and Primary Care (a) 6 N/A under TRICARE Program 2017 114-328 Sec. 705, Value-Based Purchasing and (b),(d) 2 N/A Acquisition of Managed Care Support Contracts For TRICARE Program (as amended by FY18 Sec. 715 and FY20 Sec. 716) 2017 114-328 Sec. 718, Enhancement of Use of Telehealth (a)(1)-(2), (b)-(d), 8 N/A Services In Military Health System (e)(1)-(2), (f)(1)- (3) Page 54 GAO-23-105710 Defense Health Care Appendix III: Military Health System Reform Requirements from Fiscal Years 2012 through 2022 that DOD Completed Actions to Address Public NDAA Law NDAA Number of Related GAO fiscal yeara number NDAA section number and title subsection(s) requirements reports 2017 114-328 Sec. 729, Improvement of Health Outcomes (a)-(e) 2 GAO-20-695R and Control of Costs of Health Care Under TRICARE Program Through Programs to Involve Covered Beneficiaries (as amended by FY22 Sec. 719) 2018 115-91 Sec. 702, Modifications of Cost-Sharing (a) 2 N/A Requirements for the TRICARE Pharmacy Benefits Program and Treatment of Certain Pharmaceutical Agents Category: Training and readiness 2017 114-328 Sec. 707, Joint Trauma System (a)(1)-(2) 2 GAO-18-300 2017 114-328 Sec. 708, Joint Trauma Education and (a), (c)(1)-(4), 10 GAO-20-165 Training Directorate (d)(1),(d)(3), (e) 2017 114-328 Sec. 717, Evaluation and Treatment of (a), (b)(1), (c)(1)- 5 GAO-22-104770 Veterans and Civilians at Military Treatment (3) Facilities (as amended by FY18, Sec. 712) 2017 114-328 Sec. 749, Oversight of Graduate Medical (a), (b) 2 GAO-19-338 Education Programs of Military Departments 2019 115-232 Sec. 732, Joint Forces Medical Capabilities (a), (c) 2 N/A Development and Standardization 2020 116-92 Sec. 743, Study and Plan on the Use of (a), (b), (c)(1)-(2) 4 N/A Military-Civilian Integrated Health Delivery Systems Legend: N/A = not applicable. Source: GAO analysis of National Defense Authorization Acts (NDAA) and Department of Defense (DOD) information. | GAO-23-105710 Notes: We identified requirements related to reforming the military health system in the NDAAs from fiscal years 2012 through 2022 and grouped the requirements into five categories: Governance and Administration; Force Structure and End Strength; Medical Treatment Facility Care; Private-Sector Care; and Training and Readiness. Although some requirements overlap categories of reform, we assigned each requirement to a single category and counted each requirement once. For example, sections 706 of the NDAA for Fiscal Year 2017 and 743 of the NDAA for Fiscal year 2020 include requirements related to private-sector care as well as requirements related to training and readiness. We assigned both sections to the Training and Readiness category. Additionally, we identified four requirements in the Private-Sector Care category that were within our scope of MHS reforms but for which we were unable to determine the extent to which DOD addressed them. This occurred for various reasons, such as information that DOD was required to post online no longer being available, and as a result, we are not including them in our counts of DOD's actions. Citations to specific subsections, paragraphs, or subparagraphs of NDAA sections listed in the table as requirements may not be inclusive of all subordinate paragraphs, sub-paragraphs, or clauses. In some instances, subordinate provisions related to the requirement; in other instances, the subordinate provisions did not relate to requirements within our scope. While some of these requirements were codified in various sections of the U.S. Code, we only include citations to the original public law section in which each requirement was enacted or amended. Subsections identified in this table reflect amendments enacted through the NDAA for Fiscal Year 2022. a The table does not include the dates that the NDAAs were enacted. b Section 718 of the NDAA for Fiscal Year 2021 amends section 703(d) of the NDAA for Fiscal Year 2017 by requiring the Secretary of Defense to submit additional information to the congressional defense committees as a part of the implementation plan for restructure or realignment of military Page 55 GAO-23-105710 Defense Health Care Appendix III: Military Health System Reform Requirements from Fiscal Years 2012 through 2022 that DOD Completed Actions to Address medical treatment facilities. The Secretary provided this information to the congressional defense committees in July 2022. Pub. L. No. 116-283, § 718(1) (2021). c Pub. L. No. 117-81, § 731(b)(2) is a forward-looking requirement that extends through fiscal year 2027. DOD has addressed it so far by reporting current personnel levels and projections. Page 56 GAO-23-105710 Defense Health Care Appendix IV: Comments from the Appendix IV: Comments from the Department of Defense Department of Defense Page 57 GAO-23-105710 Defense Health Care Appendix IV: Comments from the Department of Defense Page 58 GAO-23-105710 Defense Health Care Appendix V: GAO Contact and Staff Appendix V: GAO Contact and Staff Acknowledgments Acknowledgments Brenda S. Farrell, (202) 512-3604 or FarrellB@gao.gov GAO Contact In addition to the contact named above, Lori Atkinson (Assistant Director), Staff Melissa Blanco (Analyst in Charge), Bonnie Anderson (Assistant Acknowledgments Director), Kaitlin Asaly, Danielle Bernstein, Christopher Gezon, Alexandra Gonzalez, Jacquelyn Hamilton, Jesse Jordan, Lillian Ofili, Patricia Powell, Michael Shaughnessy, William Tedrick, and Lillian Moyano Yob made key contributions to this report. Page 59 GAO-23-105710 Defense Health Care The Government Accountability Office, the audit, evaluation, and investigative GAO's Mission arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO's commitment to good government is reflected in its core values of accountability, integrity, and reliability. The fastest and easiest way to obtain copies of GAO documents at no cost is Obtaining Copies of through our website. Each weekday afternoon, GAO posts on its website newly GAO Reports and released reports, testimony, and correspondence. You can also subscribe to GAO's email updates to receive notification of newly posted products. Testimony Order by Phone The price of each GAO publication reflects GAO's actual cost of production and distribution and depends on the number of pages in the publication and whether the publication is printed in color or black and white. Pricing and ordering information is posted on GAO's website, https://www.gao.gov/ordering.htm. Place orders by calling (202) 512-6000, toll free (866) 801-7077, or TDD (202) 512-2537. Orders may be paid for using American Express, Discover Card, MasterCard, Visa, check, or money order. Call for additional information. Connect with GAO on Facebook, Flickr, Twitter, and YouTube. Connect with GAO Subscribe to our RSS Feeds or Email Updates. Listen to our Podcasts. Visit GAO on the web at https://www.gao.gov. Contact FraudNet: To Report Fraud, Website: https://www.gao.gov/about/what-gao-does/fraudnet Waste, and Abuse in Automated answering system: (800) 424-5454 or (202) 512-7700 Federal Programs A. Nicole Clowers, Managing Director, ClowersA@gao.gov, (202) 512-4400, U.S. Congressional Government Accountability Office, 441 G Street NW, Room 7125, Washington, Relations DC 20548 Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800 Public Affairs U.S. Government Accountability Office, 441 G Street NW, Room 7149 Washington, DC 20548 Stephen J. Sanford, Managing Director, spel@gao.gov, (202) 512-4707 Strategic Planning and U.S. Government Accountability Office, 441 G Street NW, Room 7814, External Liaison Washington, DC 20548 Please Print on Recycled Paper.