Department Planning Processes for Operational Medical Personnel Requirements Do Not Include an Assessment of All Medical Personnel or the Full Cost of Military Personnel

The military departments each have their own process to determine their  operational medical personnel requirements. DOD Has Not Assessed Using Federal Civilians or Contractors to Meet Operational Medical Personnel Requirements

The military departments have not assessed the extent to which federal  civilians and contractor personnel can be used to meet identified  operational medical personnel requirements. Officials also expressed  concern regarding their military department’s ability to identify and recruit  federal civilians and contractors for such positions. In certain DOD  functional communities, federal civilians and contractors play a critical  role in combat support roles. Federal civilians and contractors are not incorporated into the military  departments’ planning to meet operational medical requirements because  DOD has not performed an assessment of the suitability of federal civilian  or contractor personnel to provide operational medical care. The Military Departments Do Not Consider the Full Cost of Active and Reserve Component Medical Personnel When Planning for Operational Requirements and Do Not Have Full Cost Information

The military departments’ planning to meet DOD’s operational personnel  requirements generally do not consider the full cost of active and reserve  component personnel when determining the balance of active and  reserve component medical forces. In a 2013 DOD report, DOD identified the cost of unit manning, training,  and equipping as one of five factors that play a key role in decisions  concerning the mix of active and reserve component forces. Further, DOD policy states that workforce decisions must be  made with an awareness of the full costs of personnel to DOD and more  broadly to the federal government, and highlights that the full cost of  active duty personnel extends beyond cash compensation, and also  includes other costs such as education and training. The Military Departments Have Established a Process to Assess the Appropriate Workforce Mix for Beneficiary Care within MTFs, but Face Challenges in Executing Their Plans

The military departments have taken actions, such as establishing  policies and procedures, to aid the execution of the appropriate workforce  mix for providing beneficiary health care within MTFs. The  military departments therefore prioritize the distribution of military  personnel across MTFs, and then consider how to fill the remaining  authorizations with federal civilian personnel or by contracting medical  services as appropriate. Our review,  including interviews with military department officials responsible for  medical personnel management and with the senior leadership of six  MTFs, highlighted, as discussed below, the following distinct challenges:  (1) the length of federal civilian hiring and contracting process, (2)  uncompetitive federal civilian salaries and contractor compensation, and  (3) FTE targets and hiring freezes. Senior officials at each of the six MTFs  we spoke with stated the federal civilian hiring process, including its  length and restrictions imposed by statute or policy, impedes their ability  to hire desirable federal civilian candidates. Senior officials at each of the six  MTFs stated it is a challenge to fill federal civilian medical positions  because of lower salaries compared to the private sector. Senior officials from five of six MTFs reported  discontinuing some services as a result of these challenges and referred  patients to the TRICARE network or to Veterans Affairs facilities. According to  GAO’s key questions to assess agency reform efforts, strategic workforce  planning should precede any staff realignments or downsizing, so that  changed staff levels do not inadvertently produce skills gaps or other  adverse effects that could result in increased use of overtime and  contracting. (Recommendation 4)
The Secretary of Defense and the Secretaries of the Army, the Navy, and  the Air Force, respectively, should ensure that accompanying the transfer  of administrative responsibility for military treatment facilities to the  Defense Health Agency, that the Defense Health Agency and the military  departments develop policies and procedures for management of military  personnel, including agreement on specific roles and responsibilities for  the military departments and the Defense Health Agency in this process. (Recommendation 5)

	Agency Comments

In written comments on a draft of this report, DOD concurred with our five  recommendations concerning additional assessments needed to better  ensure an efficient MHS total workforce. Moreover, we  interviewed officials from the military departments to discuss: (1) how they  determine their operational medical requirements and if they identified the  full cost of active and reserve component medical personnel, and (2) the  use of the active and reserve components for operational requirements  and any efforts to assess the balance of active and reserve component  medical personnel. To address how the military departments determine the most appropriate  workforce mix at military treatment facilities (MTFs) and any challenges in  executing an appropriate workforce mix, we reviewed DOD and  department-level policies and guidance on workforce mix determination. To determine the proportion of  reported military, federal civilian, and contractor personnel providing or  supporting care in MTFs, we obtained budgetary data for fiscal year 2017,  which was the most recent full fiscal year of available data at the time of  our review.
Why GAO Did This Study

The MHS includes more than 241,000 active duty, reserve, federal civilian, and contractor personnel who provide (1) operational medical care in support of war and other contingencies and (2) beneficiary medical care within DOD's hospitals and clinics.
The Senate Report 115-125 accompanying a bill for the National Defense Authorization Act for Fiscal Year 2018 contained a provision for GAO to review how DOD determines its mix of military, federal civilian, and contractor personnel. This report examines the military departments' planning processes for determining (1) operational medical personnel requirements, including an assessment of the mix of federal civilian, contractor, and active and reserve medical personnel; and (2) the most appropriate workforce mix at MTFs and any challenges in executing their desired workforce mix. GAO compared MHS staffing practices with DOD policy, and analyzed fiscal year 2017 budgetary data to determine the proportion of military, federal civilian, and contractor personnel. GAO also interviewed senior leaders at six MTFs.

What GAO Found

The military departments each have their own processes to determine their operational medical personnel requirements; however, their planning processes to meet those requirements do not consider the use of all medical personnel or the full cost of military personnel. Specifically:
The Department of Defense (DOD) has not assessed the suitability of federal civilians and contractors to meet operational medical personnel requirements. Federal civilians and contractors play key roles in supporting essential missions, i.e. providing operational assistance via combat support. Military department officials expressed a preference for using military personnel and cited possible difficulties in securing federal civilian and contractor interest in such positions. An assessment of the suitability of federal civilians and contractors could provide options for meeting operational medical personnel requirements.
When determining the balance of active and reserve component medical personnel, the military departments' processes generally do not consider full personnel costs, including education and benefits. Specifically, officials stated that the Army and the Navy do not consider personnel costs in their assessment of the appropriate balance between active and reserve personnel, and the Air Force's analysis had some limitations. DOD policy states that workforce decisions must be made with an awareness of the full costs. Further, in a 2013 report, DOD identified the cost of unit manning, training, and equipping as one of five factors that play a key role in decisions concerning the mix of active and reserve component forces. By developing full cost information for active and reserve component medical personnel, DOD can better ensure an appropriate and cost-effective mix of personnel.
The military departments have taken actions, such as establishing policies and procedures, to assess the appropriate workforce mix for beneficiary care within Military Treatment Facilities (MTFs), but challenges remain. The military departments distribute military personnel across the MTFs and then use policies and procedures to consider risks, costs, and benefits to determine how to fill the remaining positions with federal civilians and contractors. However, a number of challenges, including lengthy hiring and contracting processes and federal civilian hiring freezes affect DOD's ability to use federal civilians and contractors. For example, senior officials at each of the six MTFs that GAO spoke with cited challenges with the federal civilian hiring process, and five of six MTFs cited challenges with the contracting process. As a result, senior officials from five of six MTFs reported discontinuing some services and referring patients to DOD's TRICARE network of private sector providers or Veterans Affairs facilities. The Military Health System (MHS) is also preparing for the phased transfer of administrative responsibility for MTFs to the Defense Health Agency (DHA), including management of the MTF workforce. According to GAO's report on agency reform efforts, strategic workforce planning should precede any staff realignments or downsizing. However, according to a senior official, the DHA has not developed a strategic workforce plan. Without developing such a plan, the DHA may continue to face the same challenges experienced by the military departments in executing an appropriate and efficient workforce mix at its MTFs.

What GAO Recommends

GAO recommends that DOD, among other things, (1) assess the suitability of federal civilians and contractors to provide operational medical care; (2) develop full cost information for active and reserve component medical personnel; and (3) develop a strategic total workforce plan for the DHA to help ensure execution of an appropriate workforce mix at its MTFs. In commenting on a draft of this report, DOD concurred with each of GAO's recommendations.