In September 2013, the Defense Health Agency was established to  support greater integration of clinical and business processes across the  Military Health System. Two of Three Services Use Validated Dental Clinic Staffing Models, and None of the Models Incorporate Cross- Service Standards

		The Army and the Air Force Use Validated Dental Clinic Staffing Models, and the Navy’s Proposed Model Is under Review

The Army and the Air Force have validated the dental clinic staffing  models that they use, and the Navy’s draft model is under review. In the  absence of a validated model, the Navy uses a general ratio to staff its  dental clinics. Additionally, Army officials stated that the data used in the model are  updated on an annual basis and that the model is subject to  revalidation every 5 years. As previously  discussed, the services have developed and are in the process of  implementing cross-service staffing standards—that is, a standardized  approach to staffing the common day-to-day health needs of the patient  population—for certain medical specialties. However, according to an official involved in the  development of the standards, the services have not collaborated to  develop a plan to establish a similar set of standards for dental care. Additionally, service officials  maintained that they must operate their respective dental clinics  autonomously and in a manner that best supports their service-specific  needs and unique command structures. Additionally, since  DOD is currently assessing whether it will consolidate the services’ dental  corps staff under the Defense Health Agency’s administration, it  remains unclear to us why dental care has been excluded from cross- service efforts to develop a common set of standards for staffing military  dental clinics—especially because the services have developed common  staffing standards for42 other medical specialties. The Services Generally Have Met Goals for Recruiting Dental Students, but Not for Fully Qualified Dentists and Do Not Know the Extent to Which Certain Programs Are Effective at Helping Recruit and Retain Dentists

The Army, the Navy, and the Air Force have generally met their  recruitment goals for dental students, but generally have not met their  recruitment goals for fully qualified dentists to address oral health needs  of the services. Overall, we found that the services maintained their  staffing levels for military dentists during fiscal years 2012 through 2016,  but experienced gaps within certain specialties. While the services have experienced challenges in recruiting fully  qualified dentists, the challenges are most pronounced in certain  specialties. For example, based on our analysis of service data from fiscal  years 2012 through 2016, the Army and the Navy were unable to recruit  any oral surgeons and the Air Force recruited 50 percent of the oral  surgeons it needed. Service officials cited various reasons for not being  able to meet their recruitment goals for certain specialties, including the  availability of more lucrative careers in the private sector and quality of life  concerns associated with military service, such as frequent moves. The Services Monitor Their Recruitment and Retention Programs, but Do Not Know Whether The Programs Are Effective

The services rely on programs, such as AFHPSP, the Critical Wartime  Skills Accession Bonus (CWSAB), and special pay and incentives, to  attract and retain military dentists, but they do not know the extent to  which some of these programs are effective at helping them meet their  recruiting and retention goals. While the services monitor their  progress toward recruitment and retention goals, they do not know the  extent to which the programs designed to help them meet their goals  affect their ability to recruit and retain dentists because they have not  evaluated their effectiveness. Additionally, Office of ASD(HA) and service officials stated that they will  begin reviewing the dental special pays and incentives in fiscal year 2019. However, the Army, the  Navy, and the Air Force have not collaborated in their approaches to  staffing dental clinics, and have not developed cross-service staffing  standards for dental clinic staffing. (Recommendation  2)
The Secretary of the Air Force should ensure that the Surgeon General of  the Air Force Medical Service (1) collaborate with the Army Medical  Command and the Navy Bureau of Medicine and Surgery to develop and  implement a common set of planning standards to be used to help  determine dental clinic staffing needs, and (2) incorporate these  standards into the Air Force’s dental corps staffing model. (Recommendation 4)
The Secretary of the Navy should ensure that the Surgeon General of the  Navy Bureau of Medicine and Surgery evaluates the effectiveness of its  recruitment and retention programs for military dentists, including the  need for and effectiveness of the recruitment and retention incentives  currently offered. (Recommendation 6)

	Agency Comments

We provided a draft of this report to DOD for review and comment. DOD  did not provide comments. According to officials, the services have developed and implemented  processes to continuously monitor dentist performance in accordance  with DOD policy.
Why GAO Did This Study

DOD has taken steps to modernize its Military Health System to ensure that it operates efficiently. For example, in September 2013, the Defense Health Agency was created, in part, to implement common clinical and business processes across the services. Essential to this effort are the services' ability to effectively staff their medical facilities, including the processes used for staffing dental clinics and the services' ability to recruit and retain military dentists.
Senate Report 115-125 included a provision for GAO to review the services' processes for determining requirements for dentists and its programs for recruiting and retaining military dentists, among other things. GAO assessed the extent to which the services (1) use validated dental clinic staffing models that also incorporate cross-service staffing standards, and (2) have recruited and retained military dentists and measured the effectiveness of their recruitment and retention programs. GAO assessed service dental clinic models, analyzed recruitment and retention data from fiscal year 2012 through 2016, and interviewed DOD and service officials.

What GAO Found

The Army and the Air Force use validated staffing models for their respective dental clinics, and the Navy has developed a model that is under review. The Army and the Air Force's models are based on service-specific staffing standards. For example, the Army's model generally projects dental clinic staffing based on historical facility data and, according to officials, the Air Force model is largely a population-based model that requires one dentist for every 650 servicemembers. In contrast, in the absence of a validated model, officials stated that, the Navy uses a general ratio of one dentist for every 1,000 servicemembers to staff its dental clinics. The Navy has developed a model that is under review, and if approved, according to officials, will be subject to the Navy's validation processes.
While the services have developed and implemented cross-service staffing standards for 42 medical specialties, according to a key official involved in developing these standards, they currently do not plan to develop a similar set of standards for dental care. Cross-service staffing standards help the services standardize clinic staffing to address the common day-to-day health needs of patients. Service officials maintain that they must operate their respective dental clinics autonomously and in a manner that best supports their service-specific needs and unique command structures. However, as oral health requirements for servicemembers are standardized across the Department of Defense (DOD), it is unclear why dental care has been excluded from the staffing standardization effort—especially because the services have implemented cross-service staffing standards for 42 other medical specialties.
The Army, the Navy, and the Air Force meet their needs for military dentists by recruiting both dental students and fully qualified dentists. The services generally met their recruitment goals for dental students between fiscal years 2012 and 2016, but faced challenges recruiting and retaining fully qualified dentists during that period. For example, the Army missed its recruitment goals for fully qualified dentists in all 5 years, the Navy missed its goals in 2 out of 5 years, and the Air Force missed its goals in 3 out of 5 years. These challenges are most pronounced for certain specialties. For example, service data indicate that the Army and the Navy were unable to recruit any oral surgeons, while the Air Force recruited 50 percent of the oral surgeons it needed. Service officials cited various reasons for not meeting recruitment goals, including the availability of more lucrative careers in the private sector and quality of life concerns associated with military service.
The services rely on various programs, including scholarships and special pay and incentives, to attract and retain military dentists, and service officials stated that they monitor their programs by reviewing their goals, among other actions. However, GAO found that some services continue to provide incentive bonuses for positions that are overstaffed and have met or exceeded recruitment goals, but they do not know whether this is necessary because they have not evaluated the effectiveness of their programs. Without evaluating their programs, the services lack the information necessary to ensure that they are using recruitment and retention incentives effectively and efficiently for attracting and retaining dentists.

What GAO Recommends

GAO recommends that each of the services develop cross-service staffing standards to be incorporated into their staffing models, and evaluate the effectiveness of their recruitment and retention programs. DOD did not provide comments on a draft of this report.