These measures may  be used to assess the quality of care in various settings, including  hospitals and physician offices. Similarly, a number of military hospitals report on surgical quality  measures to the National Surgical Quality Improvement Program. The MHS Does Not Use a Common Set of Quality Measures for Direct and Purchased Care

Although the NDAA 2016 directed the MHS to align its quality measures  for direct and purchased care, we found that as of March 31, 2018, the  MHS used separate sets of measures on the Core and Purchased Care  Dashboards to assess the quality of care delivered in direct and  purchased care, respectively. 2.) However, for purchased care, the MHS uses its quality measures on the  Purchased Care Dashboard to assess the quality of care delivered to the  beneficiary population served by each contractor’s network as a whole– not the quality of care delivered by individual civilian hospitals, clinicians,  or other providers in the network. The MHS Uses Quality Measures that Assess a Limited Range of Quality Care Areas and Medical Conditions Compared to Measures Adopted by Medicare and Private Health Insurers

We found that the measures the MHS uses on its Core and Purchased  Care Dashboards to assess the quality of direct and purchased care  address only a limited range of quality areas and medical conditions when  compared with the Hospital Compare and CQMC measure sets that are  adopted by Medicare and private health insurers. Because the MHS does not prioritize expanding the range of medical  conditions and quality areas covered by common measures across direct  and purchased care, the measures the MHS uses provide DOD’s senior  health care leadership with an incomplete picture of the quality of care  across the MHS. The MHS Has Established Performance Standards and Related Corrective Action Requirements for Individual Providers in Direct Care but Not in Purchased Care

The MHS has established performance standards in direct care related to  the Core Dashboard measures and has corrective action requirements for  MTFs that do not meet the standards. The military services—Army, Navy and Air Force—and DHA have  been responsible for implementing this requirement. The use of performance standards and corrective action requirements for  individual hospitals, clinicians, or other providers who serve MHS  beneficiaries is consistent with federal internal control standards for  monitoring, which state that management should establish monitoring  activities, evaluate the results, and remediate any deficiencies. By not establishing consistent performance  standards at the provider-level for direct and purchased care and  requiring corrective action requirements to ensure that these standards  are met by providers in both direct and purchased care, the MHS is  limited in its ability to address variation in the quality of care delivered. Conclusions

Congress directed DOD to reduce variation in the quality of care  beneficiaries receive through the MHS. The limitations we identified in the MHS’s Core and  Purchased Care Dashboard quality measures reflect the fact that in its  annual measure selection process, the MHS does not prioritize aligning  the quality measures across direct and purchased care and expanding  the range of measures it uses across the two systems of care. Performance standards and related  corrective action requirements are critical for holding both MTFs and  individual civilian providers accountable for providing quality care. (Recommendation 1)
The Assistant Secretary of Defense for Health Affairs should establish, as  appropriate, performance standards related to the Purchased Care  Dashboard measures that are consistent with the MHS’s performance  standards for direct care; ensure they are applied to individual purchased  care providers; and take steps, such as amending its managed care  support contracts, if necessary, to require corrective actions to be taken  when providers do not meet those standards. In its written  comments, DOD concurred with both of our recommendations.
Why GAO Did This Study

The National Defense Authorization Act for fiscal year 2016 contains provisions for GAO to review DOD's plans to (1) improve the experience of beneficiaries who receive care through military hospitals and clinics or from civilian providers and (2) reduce variation in the quality of care.
In this report, GAO examines (1) measures DOD uses to assess the quality of direct and purchased care, and (2) the extent to which DOD has established performance standards related to the measures and corrective action requirements for providers who do not meet those standards.
GAO reviewed the measures in DOD's Core Dashboard for direct care and Purchased Care Dashboard for purchased care. It also reviewed DOD documents and reports to Congress, and interviewed MHS officials, including officials from the Army, Navy, and Air Force. GAO also compared the quality measures DOD uses to those used in Medicare and by private insurers, which have been vetted by multiple stakeholders. GAO assessed DOD's use of performance standards and corrective action requirements in the context of federal internal control standards.

What GAO Found

The National Defense Authorization Act for fiscal year 2016 (NDAA 2016) directed the Department of Defense (DOD) to align its measures of health care quality used in the Military Health System (MHS) to improve beneficiary experience and reduce variation in the quality of care. GAO reviewed the quality measures DOD identified in March 2017 in response to the NDAA 2016; DOD senior leadership tracks these measures on dashboards to gauge progress on MHS strategic goals. GAO found that DOD does not use a common set of measures on its dashboards to assess the quality of care provided by either military hospitals and clinics—known as direct care—or networks of civilian hospitals and other providers, known as purchased care. (See figure.) As a result, DOD's senior leadership has limited information on the extent to which MHS beneficiaries receive consistently high quality care across the MHS.
Furthermore, for both direct and purchased care, DOD uses measures on its dashboards that track a limited range of quality care areas and medical conditions compared to the measures adopted by Medicare and by private health insurers. For example, whereas civilian hospitals report to Medicare information on 11 measures of patients' self-reported experience in hospitals, Military hospitals report only 1 such measure. By using a limited range of quality measures, DOD may not detect key quality issues. Further, when selecting quality measures, the MHS does not prioritize using common measures across direct and purchased care or expanding the range of measures it uses.
GAO also found that for direct care DOD has established performance standards and corrective action requirements for military hospitals or clinics that do not meet those standards in direct care. The performance standards indicate the level of performance providers should meet on the various quality measures DOD tracks on its dashboards, and the corrective action requirements instruct providers to take steps to improve care. However, for purchased care, DOD has not established similar performance standards for individual providers. Without consistent performance standards and corrective action requirements, DOD is limited in its ability to address variation in the quality of care delivered and help ensure that its beneficiaries receive consistent high quality care across the MHS.

What GAO Recommends

The MHS should (1) prioritize, as appropriate, selecting quality measures common for both direct and purchased care that expand the range of quality areas covered by the measures and (2) establish consistent performance standards and corrective action requirements for direct and purchased care providers. DOD concurred with both recommendations.