Surgeon General Rejects Council’s Recommendations

Notwithstanding the MEPC’s recommendations for closing GME programs at Bethesda, the Navy Surgeon General decided to close programs at Portsmouth. Moreover, about 5 months after announcing the Portsmouth GME closure decision, the Navy Surgeon General’s office completed a study of health care demographics and workload covering the Bethesda, San Diego, and Portsmouth areas, where it has major health care concentrations. No Agreement on Site Selection Criteria or Collaboration Among Those Affected

Surprised by the Portsmouth decision, medical center officials and their supporters, including a local active duty forces commander and congressional members, disagreed with the Navy’s basis for the Portsmouth GME closure decision, arguing that GME trainee losses would reduce services to active duty personnel and their dependents and other beneficiaries and would harm readiness. Army’s Closure Attempt Also Unsuccessful

While the Army’s GME sizing efforts—and the Air Force’s for that matter—are independent of the Navy’s, the services are subject to the same general policies and downsizing pressures. A few months after the Navy’s closure attempts, the Army Surgeon General acted on an internal recommendation to close all remaining GME programs at the Army’s William Beaumont Medical Center in El Paso. A representative from the Surgeon General’s office told us that the apparent proposal to concentrate GME in four geographic locations was not a factor in choosing William Beaumont. Parallels in Private Sector GME Downsizing

The private medical sector has faced and continues to face the need to reduce, close, or otherwise modify its GME programs at medical schools and hospitals. Recent Navy and Army GME program closure efforts, however, have not been successful, and the Air Force may face similar problems when it attempts closures. In deliberating closure alternatives, for example, the Navy’s MEPC did not know that (1) a change in position had occurred on preserving GME where active duty personnel are concentrated, (2) ongoing GME integration efforts were to be preserved, (3) there apparently were to be only four GME concentration centers, or (4) study results would be produced later in support of either Bethesda or Portsmouth. Recommendations

We recommend that the Secretary of Defense direct the Assistant Secretary of Defense for Health Affairs and the services’ surgeons general to collaboratively develop GME closure policy guidance and implementing criteria and processes covering such matters as key factors in identifying and winnowing potential sites, how to project and mitigate potentially adverse effects on beneficiary health care and readiness, how and when to involve those affected in the services and local areas in the decision-making process, how to reach program closure agreement, and how to communicate and implement the resulting decisions; provide in the guidance for the potential effects of such DOD and service initiatives as TRICARE, with its emphasis on cost control and primary care, that can affect GME decisions; and develop, obtain agreement on, and publish such policy guidance before any further GME closure decisions are made. Scope and Methodology

To assess the services’ experiences in downsizing their graduate medical education (GME) programs, particularly the Navy’s experiences, we examined the role of the Navy Medical Education Policy Council (MEPC) and the guidance and data the MEPC considered, evidence of the Navy’s need for GME reductions and of the expected advantages and disadvantages of closing GME programs at one location versus another, and evidence that the Navy can still achieve needed GME reductions in ways that comply with DOD guidance and that overcome the kinds of objections raised in their recent closure attempts.
Why GAO Did This Study

Pursuant to a legislative requirement, GAO reviewed a Navy advisory council's recommendations for restructuring Navy graduate medical education (GME), focusing on: (1) why the Navy did not accept its council's recommendations for Bethesda GME closures and why its other closure attempts did not succeed; (2) whether the other services already have faced or may face similar experiences; and (3) what improvements may be needed if the services are to successfully make and implement their GME sizing decisions.

What GAO Found

GAO noted that: (1) in early 1997, the Navy Surgeon General decided to eliminate 162 GME positions to comply with lower projected wartime requirements and with Department of Defense (DOD) restrictions on the ratio of physicians in training to those deployable; (2) a Navy advisory council, lacking specific guidance but responding to the Navy Surgeon General's indications that GME should occur where active duty personnel are concentrated, recommended that such training be dropped at the Bethesda Medical Center; (3) the Navy Surgeon General, however, instead decided to close some of the Navy's Portsmouth Medical Center's programs following a then newly discussed agreement among DOD and the services' surgeons general to concentrate GME in four geographic locations that included Bethesda and San Diego but not Portsmouth; (4) lacking site selection guidance, the council submitted its recommendation to the Surgeon General without taking account of the agreement, which has never been formalized or acted on by the other services; (5) when announced, the Portsmouth closure decision surprised Navy command and medical center officials there, as well as local congressional representatives; (6) publicized arguments ensued that Portsmouth was as advantageous as Bethesda for concentrating GME and that losing Portsmouth's GME would reduce trainee-provided health care to active duty personnel and other beneficiaries and would harm Navy readiness; (7) although it was unsuccessful, the Surgeon General's office tried justifying the decision and later withdrew it for further study; (8) shortly thereafter and for the same ends, the Army Surgeon General's office sought to eliminate the 64 GME positions at the William Beaumont Medical Center in El Paso, Texas, also without site selection guidance and likewise failing to involve those who were affected; (9) while the Air Force also foresees the need for GME program closures, it has not yet attempted to make them; (10) but in the absence of closure policies and criteria and judging from the Navy's and Army's closure attempt experiences, GAO has no reason to believe that the Air Force would be any more successful in bringing about required GME program adjustments; and (11) while not a direct parallel to DOD GME with its readiness dimension, private-sector medical schools and hospitals have been downsizing their GME programs and in doing so have documented success factors that may provide a useful reference for DOD in developing guidance for its future sizing efforts.