Background Composition of the MHS  Total Workforce The MHS has a dual mission of maintaining the skills of the medical force  and providing health care and beneficiary medical care in its MTFs in the  United States and overseas. It accomplishes this in part by providing (1)  operational medical care via deployable health care platforms in an  operational environment, such as forward surgical teams and combat  support hospitals, and (2) beneficiary medical care in its MTFs in the  United States and around the world. DOD’s total workforce supporting  this dual mission comprises three main components: military personnel  (including active and reserve personnel), federal civilian personnel, and  private sector contractor personnel. Active duty medical personnel  simultaneously support operational medical care and the delivery of  beneficiary health care to patients across the globe. Reserve component  medical personnel generally provide health care to deployed military  personnel, but may also provide personnel to support MTFs when active  duty personnel are deployed or otherwise unavailable. Federal civilians  and contractors generally provide beneficiary care within MTFs. Figure 1  shows the number of the active and reserve components of the military,  federal civilians, and estimated contractor full-time equivalents (FTEs)  that comprised DOD’s total medical workforce in fiscal year 2017. DOD’s Total Workforce  Provides Operational  Medical Care at Four  Levels DOD has established four levels of operational medical care provided to  servicemembers and other eligible persons. The levels of care extend  from the forward edge of the battle area to the United States, with each  level providing progressively more intensive treatment. Level 4 care  facilities are MTFs that also provide beneficiary medical care. In addition  to the four levels of medical care, en-route care to transport patients is  also provided via casualty evacuation, medical evacuation, and/or  aeromedical evacuation from the point of patient injury, illness, or  wounding. Figure 2 illustrates the different levels of care. The four levels of care are: Level 1—First responder care. This level provides immediate  medical care and stabilization in preparation for evacuation to the next  level, and treatment of common acute minor illnesses. Care can be  provided by the wounded soldiers, medics or corpsmen, or battalion  aid stations. Level 2—Forward resuscitative care. This level provides advanced  emergency medical treatment as close to the point of injury as  possible to attain stabilization of the patient. In addition, it can provide  postsurgical inpatient services, such as critical care nursing and  temporary holding. Examples of level 2 units include forward surgical  teams, shock trauma platoons, area support medical companies, and  combat stress control units. Level 3—Theater hospital care. This level provides the most  advanced medical care available in Iraq and Afghanistan. Level 3  facilities provide significant preventative and curative health care.  Examples include Army combat support hospitals, Air Force theater  hospitals, and Navy expeditionary medical facilities. Level 4—U.S. and overseas definitive care. This level provides the  full range of preventative, curative, acute, convalescent, restorative  and rehabilitative care. Examples of level 4 facilities include MTFs  such as Brooke Army Medical Center at Joint Base San Antonio,  Texas and Naval Medical Center Portsmouth at Portsmouth, Virginia. DOD Provides Beneficiary  Medical Care in the United  States and around the  World DOD’s MHS workforce provides beneficiary medical care to 9.4 million  eligible individuals, including active duty personnel and their dependents  (i.e., spouse, children), medically eligible Reserve and National Guard  personnel and their dependents, and retirees and their dependents and  survivors. Located in the United States and around the world and ranging  from small clinics to major hospitals, these facilities serve as training  platforms for active duty medical personnel to maintain their skills and  play a key role in the military departments’ Graduate Medical Education  programs for training medical professionals. In addition to the direct provision of health care in its own hospitals and  clinics, DOD maintains its TRICARE purchased care system that is used  to augment the direct care system when needed. Through regional  contracts, TRICARE administers the purchased care system, which  comprises a civilian network of hospitals and providers. Retirees who  qualify for care under Department of Veterans Affairs’ rules may also be  eligible to receive health care within the Veterans Health Administration  system of hospitals and clinics. Legislation, Policies, and  Processes Governing the  MHS Workforce Mix DOD’s management of its workforce is governed by several workforce  management statutes of title 10 of the United States Code, including: Section 129a directs the Secretary of Defense to establish policies  and procedures for determining the most appropriate and cost- efficient mix of military, civilian, and contracted services to perform the  mission of the department. Section 2463 directs the Under Secretary of Defense for Personnel  and Readiness to devise and implement guidelines and procedures to  ensure that consideration is given to using, on a regular basis, DOD  civilian employees to perform new functions and functions performed  by contractors that could be performed by DOD civilian employees. Section 2461 directs that no DOD function performed by civilian  employees may be converted, in whole or in part, to performance by a  contractor unless the conversion is based on the results of a public– private competition that formally compares the cost of performance by  civilian employees with the cost of contractors, among other  considerations. There is currently a government-wide moratorium on  performing such public-private competitions. DOD’s total workforce management policy generally emphasizes the  need for agencies to utilize the least costly mix of personnel while  ensuring the workforce is sufficiently sized, and comprised of the  appropriate mix of personnel to carry out the mission of DOD. The  departments use DOD guidance to assess the use of military, federal  civilian, and contractor personnel, which includes the consideration of two  key factors: (1) the risk to the military mission, and (2) the cost of the  workforce. To help assess risk, the departments determine what work  should be performed by military, federal civilian, or contractor personnel.  For example, work that is inherently governmental must be performed  only by military or civilian personnel, while work that is commercial in  nature could be performed by any personnel type. To make this  determination, DOD Instruction 1100.22 directs components to: use the  manpower mix criteria outlined in the instruction to identify inherently  governmental and commercial activities; and review the annual inventory  of commercial and inherently governmental activities. In addition, DOD  and the departments have established policies and procedures to assess  the costs and benefits of different workforce mix options. DOD Instruction  1100.22 directs components to conduct a cost comparison of personnel  when considering outsourcing new requirements that are not required to  be performed by government personnel, or when considering in-sourcing  functions that are currently performed by private sector contractors. Roles and Responsibilities  for Managing the MHS  Workforce Several officials have responsibility for governing DOD’s management of  its total workforce, including The Under Secretary of Defense for Personnel and Readiness  (USD(P&R)). This official has overall responsibility for issuing  guidance on total workforce management to be used by the DOD  components, providing guidance on manpower levels of the  components, and developing manpower mix criteria and other  information to be used by the components to determine their  workforce mix. The Under Secretary of Defense (Comptroller). This official is  responsible for ensuring that the budget for DOD is consistent with the  total workforce management policies and procedures. The Secretaries of the military departments and heads of the  defense agencies. These officials have overall responsibility for the  requirements determination, planning, programming, and budgeting  execution for total workforce management policies and procedures,  as well as having numerous responsibilities related to total workforce  management as detailed in DOD guidance. The Assistant Secretary of Defense for Health Affairs (ASD(HA)). This official serves as the principal advisor for all DOD health related  policies, programs, and activities. The ASD(HA) has the authority to:  develop policies, conduct analyses, provide advice, and make  recommendations to the USD(P&R), the Secretary of Defense, and  others; issue guidance; and provide oversight to the DOD  Components on matters pertaining to the MHS. Further, the ASD(HA)  prepares and submits a DOD unified medical program budget which  includes, among other things, the defense health program budget to  provide resources for the DOD MHS. The Director of the Defense Health Agency (DHA). This official,  among other things, manages the execution of policies issued by the  ASD(HA) and manages and executes the Defense Health Program  appropriation, which partially funds the MHS. Recent MHS Personnel  Reform Efforts The National Defense Authorization Act for Fiscal Year 2017 directed the  transfer of administrative responsibility for MTFs from the military  departments to the DHA. Specifically, the Director of the DHA shall be  responsible for the administration of each MTF, including budgetary  matters, information technology, health care administration and  management, administrative policy and procedure, military medical  construction, and any other matters the Secretary of Defense determines  appropriate. Since 2016, DHA’s responsibilities in the administration of  MTFs have been further articulated in DOD memoranda and in statute. In  2018, DOD directed that the DHA shall be responsible for: (1) the  planning, programming, budgeting, and execution processes for the  MTFs; (2) clinical and health delivery services in each MTF; and (3) for  these services, the hiring and management of federal civilians and  contract staffing. Further, in 2018, Congress amended the law to specify  that at each MTF, the Director of the DHA has the authority to determine  total workforce requirements, direct joint manning, and address personnel  staffing shortages, among other things. Also in December 2016, Congress enacted legislation that allows the  prohibition of converting military medical and dental positions to federal  civilian positions, which had been in place since 2008, to be lifted. This  change is contingent upon DOD satisfying a reporting requirement on the  size and composition of its operational medical force. Specifically,  Congress directed DOD to report on the process established to define the  military medical and dental requirements necessary to meet operational  medical force readiness requirements, and provide a list of those military  medical and dental requirements. 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. After determining the  number of medical personnel needed to support operational needs, the  military departments generally consider only military personnel when  conducting their planning processes to meet these requirements, and  have not formally assessed the extent to which federal civilians and  contractor personnel could be utilized. Further, the departments do not  generally consider the full cost of active and reserve component medical  personnel when determining their balance of active and reserve  component medical personnel, and they have not developed such  information to use in their assessment of active and reserve balance. Each Military Department  Has Its Own Process to  Plan for Operational  Medical Personnel  Requirements, Including  the Balance of Active and  Reserve Component  Personnel Each military department has its own process to plan for operational  medical personnel requirements. The departments’ operational medical  personnel requirements are based on their analysis of DOD’s Defense  Planning Guidance and Defense Planning Scenarios. Specifically,  possible casualty streams are estimated based on the scenarios, and the  required medical support is determined in conjunction with department- specific medical planning factors, such as rotation policy, the population  at risk, and evacuation policy, among others. Each military department  incorporates these factors to estimate the number of medical personnel  needed. The Army integrates medical planning into its general process for  estimating all operational requirements, whereas the Navy and Air Force  have separate, medical-specific processes. The following represents an  overview of each military department’s approach: Army. The Army uses its Total Army Analysis model to determine the  number and type of support units across the Army, including medical  forces, which will be needed to support the Army’s combat forces in  operational settings. Navy. The Navy uses a medical-specific model, called the Medical  Manpower All Corps Requirements Estimator, to estimate its total  medical personnel readiness requirements. The Navy readiness  mission is to support all Navy and Marine Corps operational missions,  including operational operations (such as hospital ships and  expeditionary medical facilities) and day-to-day operations (such as  ships, submarines, and Special Forces). Air Force. The Air Force uses a medical-specific sizing model named  the Critical Operational Readiness Requirements tool to project its  minimum military personnel requirements. This tool identifies the  number of military medical personnel needed to meet requirements,  including requirements for en-route casualty support, theater  hospitals, and critical care air transport teams. According to military department officials, the decision to apportion  medical personnel requirements among the active and reserve  components is based on an assessment of risk across a range of factors.  In a 2013 DOD report issued in response to section 1080A of the National  Defense Authorization Act for Fiscal Year 2012. DOD noted that there  are several important factors in active component and reserve component  mix decisions, including, among others, the timing, duration, and skills  required for anticipated missions. Moreover, the report notes that active  components are best suited for unpredictable and frequent deployments,  dealing with complex operational environments, and unexpected  contingencies and the reserve components are best suited for predictable  and infrequent deployments. As noted in the report, active component  personnel typically mobilize and deploy to theater the fastest. The sum of  these considerations results in a different mix of active and reserve  component medical personnel within each military department.  Specifically, reserve personnel (as a percentage of the total workforce)  varied by military department in fiscal year 2017, with reservists  representing 41 percent of medical personnel of the Army, 17 percent of  the Navy, and 34 percent of the Air Force, as shown in figure 3. 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. Specifically, after the military  departments have determined their operational medical personnel  requirements, they generally have designated all such positions as  “military-essential” (i.e., the activity must be performed by a military  servicemember) and have not formally assessed the extent to which  civilians or contractors could be utilized to fill these positions, according to  officials. Army, Navy, and Air Force officials stated that they have  historically relied on active and reserve component military personnel  when planning for operational medical requirements, with a few  exceptions. For example, according to Navy officials, the few federal  civilians that are planned to fill operational medical requirements are  technical representatives who do not travel on ships for extended periods  of time. In interviews, military department officials cited key reasons for not  incorporating federal civilians and contractors into their planning for  operational medical care. Specifically, officials said they did not believe  that federal civilians or contractors were viable workforce alternatives to  military servicemembers for operational medical care roles and functions  due to the unique nature of such assignments (e.g. providing medical  care in a deployed setting). Moreover, officials noted that federal civilians  and contractors supporting operational medical requirements are  generally considered to be a temporary solution. Officials also expressed  concern regarding their military department’s ability to identify and recruit  federal civilians and contractors for such positions. Officials stated that  while there is currently no guidance outlining the potential role of federal  civilians and contractors providing medical care in operational settings,  they noted that DOD workforce mix guidance includes a provision that  highlights the military-essential nature of medical personnel embedded in  non-medical units engaged in hostile action. However, this instruction  does not otherwise address the role of federal civilians and contractors in  providing medical care, including whether they can serve in medical- specific operational platforms, such as combat support hospitals providing  level 3 care. To ensure that its federal civilian employees will deploy to combat zones  and perform operational roles such as critical combat support functions in  theater, DOD established the emergency-essential civilian program in  1985. Under this program, DOD designates as “emergency-essential”  those federal civilian employees whose positions are required to ensure  the success of combat operations or the availability of combat-essential  systems. DOD’s emergency-essential workforce is now governed under  the Expeditionary Civilian Workforce program. DOD can deploy  emergency-essential federal civilian employees either on a voluntary or  involuntary basis to accomplish the DOD mission. In certain DOD  functional communities, federal civilians and contractors play a critical  role in combat support roles. For example, as we previously reported,  DOD relies on the federal civilian personnel it deploys to support a range  of essential missions, including logistics support and maintenance,  intelligence collection, criminal investigations, and weapons system  acquisition and maintenance. Further, as we have previously reported,  DOD has long used contractors to provide supplies and services to  deployed forces. Since the early 1990s, much of this support has come  from logistics support contracts—contracts that are awarded prior to the  beginning of contingencies and are available to support the troops as  needed. Although they are generally not a part of the military departments’  planning processes, and there is no guidance dedicated to delineating the  role of federal civilians and contractors in providing care in deployed  operational settings according to officials, these personnel have deployed  within the past 5 years. Based on our analysis of DOD federal civilian  deployment data—for fiscal years 2013 through 2017—about 120 DOD  federal civilians, including nurses, physicians, and technicians, were  deployed to provide medical services. U.S. Central Command officials  stated that they have used federal civilians minimally, and U.S. Africa  Command officials stated they have not used federal civilians. In  addition, based on our analysis of DOD contractor deployment data for  deployments from fiscal years 2013 through 2017, there were more than  1,900 deployed contractors providing medical services. U.S. Central  Command officials told us that they have not used contractors to provide  care to military personnel. Officials noted that the deployed contractors  were not contracted by DOD for purposes of providing medical care and  instead provided medical care to other contractors as they were part of a  larger contract for other services, such as security services or logistics  support. U.S. Africa Command officials told us that they have used  contractors to provide medical care to support casualty evacuation and  personnel recovery requirements, which includes providing medical care  to military personnel and other eligible persons. Officials with the Joint Staff Surgeon’s Office and the Surgeon’s offices at  U.S. Central Command and U.S. Africa Command agreed with the  possibility of using federal civilians and contractors for certain operational  medical personnel requirements. Specifically, officials stated that federal  civilians and contractors likely represent an acceptable workforce  alternative if they are medically ready to deploy and appropriately trained  for the unique environment at a fixed facility in theater, such as a level 3  fixed expeditionary medical facility or theater hospital. While agreeing that the use of federal civilians and contractors for certain  operational medical personnel requirements may be acceptable, officials  also expressed concerns with this approach. A senior official with the U.S.  Central Command Surgeon’s office noted concerns regarding the pre- deployment training provided to contractors. Specifically, the official  stressed the importance of such training to operating effectively in the  unique operational environment of a deployed medical team and that  such training is only required to be completed by military personnel and  DOD expeditionary civilians. U.S. Africa Command officials expressed  concerns regarding challenges in obtaining clinical privileging rights (i.e.,  the right for a physician to perform specific health care services) for  contractors supporting small teams in an operational setting. Further,  OASD(HA) officials noted that a key factor to determining if federal  civilians or contractors should be used to provide operational medical  care is whether or not using those workforces would achieve any cost  savings. Moreover, officials with the Defense Civilian Personnel Advisory Service  noted that they have had limited success with using DOD’s Expeditionary  Civilian Workforce program for the provision of medical administrative  support and medical advising functions. A senior official from the U.S.  Central Command Surgeon’s office noted this was due to relatively few  qualified federal civilians within the program with medical skills. Defense  Civilian Personnel Advisory Service officials noted that the fiscal year  2019 force pool that defines the number and types of federal civilian  requirements needed for the program included 7 medical related positions  and none of these were for medical care; 1 was administrative and 6 were  medical advisors. Defense Civilian Personnel Advisory Service officials  stated that the DHA has a responsibility to build 1 or 2 of the medical  advisor positions in the force pool into their planning as a continuing  requirement, and noted that DHA has made some recent progress with 1  medical advisor scheduled to deploy in fiscal year 2019. While there may  be challenges with utilizing federal civilian personnel to fulfill operational  medical requirements, DOD also faces challenges with regard to military  personnel. In 2018, we reported that DOD has experienced gaps between  its military physician authorizations (i.e., funded positions) and end  strengths (i.e., number of physicians), and that it did not have targeted  and coordinated strategies to address key physician shortages. DOD has issued several documents to guide total workforce and  personnel planning. DOD Directive 1100.4 states that authorities should  consider all available sources when determining workforce mix, including  federal civilians and contractors. Moreover, DOD’s 2017 Workforce  Rationalization Plan recognizes DOD’s federal civilians as an essential  enabler of its mission capabilities and operational readiness and noted  that there are numerous opportunities for the military departments,  combatant commands, and others to make well-reasoned adjustments to  workforce mix. Further, DOD’s National Defense Business Operations  Plan for Fiscal Years 2018 to 2022 states that workforce rationalization  strategies include, among other things, reassessing military manpower  allocations for military essentiality, determining whether workload requires  deployments and whether traditional military performance is necessary,  and identifying functions and positions that are commercial in nature that  may be appropriately or efficiently delivered via private sector support. 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. Such an  assessment could assist in developing policy for use by medical planners  in determining when, where, and how federal civilians or contractors may  serve in operational roles. For example, an assessment may include what  level(s) of care would be appropriate for federal civilians and contractors  to support, if any, and factors to take into consideration in making such  decisions, such as exposure to danger and cost. By conducting such an  assessment and incorporating the results into relevant policies, DOD can  have greater certainty that it is planning for the most appropriate and  cost-effective mix of personnel to meet the mission, and, depending on  the outcome of the assessment, more options to meet its operational  medical personnel requirements. 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. Officials from Army and Navy medical  headquarters stated that cost generally does not inform their decisions  about the balance of active and reserve personnel. Army officials noted  they consider cost of a unit when making tradeoffs within the reserve  component; however, cost was not cited by Army officials as a factor  when determining between the active and reserve components. Navy  officials noted that while it uses certain cost information when preparing  the President’s budget submission, cost is not explicitly considered when  determining the balance of the active and reserve components. The Air  Force is the only military department that has performed an assessment  of the cost effectiveness of using active or reserve component medical  personnel, although it had some limitations and did not impact the Air  Force’s active and reserve component mix decisions. Army, Navy, and Air  Force officials cited other key factors which they consider in determining  the balance of active and reserve component personnel, such as the  availability of forces to deploy quickly, length of time needed in theater,  capability needed, and frequency of deployments. Moreover, the military departments have not developed full cost  information of medical personnel to use in their assessment of active and  reserve balance. Army and Navy officials stated that they do not maintain  full cost information on its active component and reserve component  medical personnel. Navy provided programming cost for the reserve  component but these rates were averages across the reserve component  and not specific to medical. The Air Force’s 2016 High Velocity Analysis  attempted to assess the cost of active and reserve medical personnel and  identify potential efficiencies within its medical workforce. However, this  study was limited because it did not include the full cost of active and  reserve component medical personnel. Specifically, the Air Force analysis  considered only compensation and did not consider other benefits, such  as medical education costs, and used average pay for officers and  enlisted personnel regardless of the specialty or skill level. However, the  full costs for certain medical personnel, such as officers, are generally  higher than average military pay, as they are eligible for a significant  number of special pays and benefits, such as graduate medical education  and training. In fiscal year 2017, DOD obligated $788 million for special  pays for active duty medical personnel, representing approximately 24  percent of the $3.3 billion obligated for all special pays across DOD, and  $707 million for medical education. While the Air Force had full cost data  for active component personnel, according to officials, they did not  include it in their analysis because they did not have comparable cost  data for the reserve component. Reserve medical personnel, when not  mobilized, receive a fraction of what active duty personnel receive, and  typically do not encumber significant education and training costs as  reserve medical personnel generally are recruited as fully trained medical  professionals. We have previously reported that when the reserve forces can  successfully meet deployment and operational requirements, individual  reserve-component units are generally less costly than similar active- component units. However, the full cost of medical personnel can vary  based on a number of factors. Specifically, more than one reserve- component unit may be needed to achieve the same output as a single  active-component unit. For example, the Army has a policy that states  reserve-component physicians, dentists, and nurse anesthetists shall not  be deployed for longer than 90 days. Thus, the Army would need to  deploy four different reserve component physicians for successive 90-day  rotations to fill a single 1-year active component requirement. Therefore,  in some cases, using reserve units to achieve the same operational  capacity over time may be more costly than using active units. However,  the lack of full cost information on active and reserve component medical  personnel is a barrier to an analytical-based determination on the balance  between active and reserve component medical personnel. In 2013, we reported limitations with the DOD-wide software tool  developed by Cost Assessment and Program Evaluation—the Full Cost  of Manpower—which, among other things, is used to identify the full cost  of active duty military personnel.  Specifically, we reported that this tool  has certain limitations for determining cost for certain cost elements. For  example, instead of determining training cost by specialty, it estimates  such costs by dividing total funding for such cost estimates by the number  of military personnel. We recommended, among other things, that DOD,  in order to improve its estimates and comparisons of the full cost of its  workforces, develop guidance for cost elements that users have identified  as challenging to calculate, such as general and administrative,  overhead, advertising and recruiting, and training. DOD partially  concurred with this recommendation but has not implemented this  recommendation. We continue to believe that developing such costs is  needed, especially for the medical community since training and  education costs can be higher than in other communities. Moreover, in  that report we also found that DOD did not include Reserve and National  Guard personnel in their methodology for estimating and comparing the  full cost to the taxpayer of work performed. We recommended DOD,  among other things, develop business rules for estimating the full cost of  National Guard and Reserve personnel. DOD partially concurred with this  recommendation but has not implemented the recommendation and  noted that a cost estimating function for reserve component personnel  would be more complex than for active component and DOD federal  civilian cost estimates. While we agree that developing cost estimates for  the reserve component could be more complex, we continue to believe it  is advisable for DOD to implement our recommendation. 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. According  to the report, cost is often outweighed by other factors when making  active component and reserve component mix decisions, but should  always be considered in active component and reserve component mix  decisions. 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 do not assess the full cost of personnel when  determining the balance of active and reserve component medical forces  because there is no DOD requirement to do so. Although DOD guidance  states that cost is one of several factors that should be considered in  active and reserve component balance decisions, the military  departments have not conducted assessments of the full cost of active  and reserve component personnel to inform their decisionmaking.  Further, DOD and the military departments are unable to conduct any such assessments because they have not developed full cost information  for active and reserve component medical personnel. Without developing  full cost information for active and reserve component medical personnel  and using that information in its determinations regarding the correct  balance of such personnel, decision makers will not have complete  information to make cost-effective choices about the balance of active  and reserve component medical personnel. 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. However, the  military departments face challenges in executing their plans in several  areas, including lengthy hiring and contracting processes and  uncompetitive salaries and compensation. Further, the transfer of  administrative responsibility for MTFs from the military departments to the  DHA may present challenges to the management of the military medical  personnel. The Military Departments  Have Established Policies  and Procedures to  Evaluate the Risks, Costs,  and Benefits of the Use of  Personnel within Its  Military Treatment  Facilities The military departments manage the workforce within their MTFs by  using various policies and procedures to determine their workforce needs  and help assess the risks, costs, and benefits of using military, federal  civilian, and contractor personnel to carry out their missions. Currently,  each military department is responsible for determining its MTF personnel  requirements: that is, the number of personnel needed to operate its  MTFs based on predicted demand for health care from their military and  beneficiary populations. To determine MTF personnel requirements, the  military departments use their respective suite of manpower models or  standards based on a number of factors, including historical medical  workload information and the size of population eligible for care.  According to Army and Navy medical command officials, the Army and  Navy suites of models respectively include at least 36 and 46 medical  specialties, and generally express historical medical workload in relative  value units, a metric of the level of professional time, skill, training and  intensity to provide a given clinical service. In contrast, according to Air  Force medical agency officials, the Air Force suite of standards includes  11 medical specialties and expresses workload in patient encounters. According to military department officials, when considering how to meet  their MTF personnel requirements given available resources, the number  of military personnel is fixed and must be preserved since the operational  medical personnel requirements support the readiness mission. 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. To make these decisions, the military  departments utilize DOD workforce guidance, which requires a balance of  risk and cost, but states that risk mitigation shall take precedence over  cost-related concerns when necessary. DOD total workforce policies  and procedures are outlined in: (1) DOD Directive 1100.4, which  establishes guidance for total workforce management; and (2) DOD  Instruction 1100.22, which outlines policies and procedures for  determining the appropriate mix of personnel. In 2018, we reported that a  DOD study found that the cost of federal civilian and contractor full-time  equivalents varied by organization, location, and function being  performed. According to Army, Navy, and Air Force officials, any  changes to funded positions are made through formal processes and  require an evaluation of the cost of the personnel options and the  approval of the military departments’ respective medical commands or  agencies. The military departments’ collective decisions determine their workforce  mix. Figure 4 shows the number and percentage of each personnel type  that provided or supported care in DOD-owned and operated MTFs for  fiscal year 2017, in the United States and overseas. Military Departments Face  Challenges in Executing  Workforce Mixes at  Military Treatment  Facilities, and DHA Does  Not Plan to Develop a  Strategy to Address These  Challenges The military departments face challenges to implementing their workforce  mix of military, federal civilian, and contractor personnel. 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. Length of Federal Civilian  Hiring and Contracting Process Federal civilian hiring process. 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. Officials primarily attributed  delays to the extended time for human resources offices to post a position  and to process and refer applicants for interviews. For federal civilian  personnel in DOD medical locations in fiscal year 2018, DOD officials  reported an average hiring time of: 121 days for the Army, 157 days for  the Navy, and 134 days for the Air Force. Legal restrictions can also extend the hiring process and hinder hiring  desirable federal civilian candidates. For example, senior officials at five  of six MTFs cited a statute requiring a 180-day waiting period before  retired military personnel can be hired as DOD federal civilians and noted  valuable candidates with military-specific subject matter expertise will  instead seek employment in the private sector. Senior officials from one  Air Force MTF stated they successfully submitted waivers to bypass the  180-day waiting period, but senior officials from one Army and one Navy  MTF stated that the waiver process often takes as long as the waiting  period. Senior officials from each of the six MTFs stated that hiring authorities,  such as direct or expedited hiring authority, can help address challenges,  but officials at four of six MTFs also expressed concerns about the  adequacy of such flexibilities. Direct-hire authority allows agencies to fill  occupations that have a severe candidate shortage or a critical hiring  need, and is meant to expedite hiring. DOD designated a number of  health care occupations as shortage category positions or critical need  occupations in accordance with this expedited hiring authority. In 2017,  DOD reported that it used expedited hiring authority in approximately 30  percent of hiring actions for its medical employees. Officials from one  Navy MTF stated they have direct hiring authority, but their human  resources office extends the process by requiring that the position be  announced within the last 90 days, or else be re-announced, before they  can utilize it. Army officials from one MTF stated interest in expanding the  list of medical specialties granted direct hiring authority. Air Force officials  from one MTF stated direct hire authority can help obtain qualified  candidates, but does not necessarily shorten the hiring process. Challenges in the federal hiring process are a longstanding issue. In  2003, we reported on the need to improve executive agencies’ hiring  process, with the majority of federal agencies included in our review  reporting that it takes too long to hire quality employees. Our 2016  review of the extent to which federal hiring authorities were meeting  agency needs found that the Office of Personnel Management (OPM) and  other agencies do not know if the authorities are meeting their intended  purposes. In 2018, we reported that DOD’s review of selected sites,  including two MTFs, found: varying use of hiring authorities, management  unfamiliarity with all available authorities, and a belief among managers  that expanded use of some authorities is needed to produce more quality  hires. Finally, our 2018 review of DOD laboratories’ use of hiring  authorities found that officials used hiring authorities, but identified  challenges such as delays in processing the personnel action and the  overall length of the hiring process. Contracting process. Senior officials at five of six MTFs stated there are  challenges in obtaining contractor services, including the process time  before personnel are available to perform work and restrictions imposed  by statute. Senior officials from two Air Force MTFs stated that after the  contract is awarded, contractors may have up to 60 days to present a  candidate; officials from one MTF stated if the MTF rejects the candidate,  then the vendor has another 30 to 60 days to find a candidate. According  to officials at one Air Force MTF, at times they have to consider whether  to accept a subpar candidate or leave a position vacant. Further, senior  Air Force officials stated that controls on contract spending limit their  flexibility in hiring. To help fill temporary contract positions, which are less  attractive to candidates, officials stated the Air Force pays higher rates to  the vendor that include the salaries of the personnel and vendor’s  overhead costs. In 2018, we reported that DOD’s negotiated price of a  contract includes direct costs, such as labor and non-labor costs, and  indirect costs, such as overhead, and service contractor profit. Senior  officials from the two Army MTFs stated that the moratorium on public- private competitions is a challenge because they cannot outsource  federal civilian functions to contracted services when there are shortages  of military or federal civilian personnel, even when it is the optimal choice.  For example, according to officials, contractors cannot perform the  functions of a civilian position when a civilian position is vacated. Uncompetitive Federal Civilian  Salaries and Contractor  Compensation Federal civilian employee salaries. 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. In 2017, DOD  reported difficulty hiring and retaining health care workers due to  competition from the private sector, among other things. We have  previously reported challenges related to the ability to provide competitive  salaries for some DOD health care providers. Specifically, in 2015 we  reported that officials from all three military departments stated their  inability to create compensation packages for federal civilian mental  health providers to compete with the private sector affected their  recruiting and retention of providers. In 2018, we noted similar concerns  in recruiting military physicians. Senior officials from each of the six MTFs we spoke with stated that the  ability to utilize hiring flexibilities, such as special salary rates, helps  mitigate this challenge, but at four of six MTFs also expressed concerns  about their adequacy. To provide higher pay for some occupations, OPM  may establish a higher salary rate for an occupation or group of  occupations in one or more geographic areas to address existing or likely  significant handicaps in recruiting or retaining well-qualified employees.  Senior officials from four of six MTFs stated special salary rates are  helpful but not sufficient. Officials at one Navy MTF noted that two  primary care providers left within the last year for better pay in the private  sector, negatively affecting access to care. Officials at one Army MTF  noted that the application for special salary rates can take 2 years or  more, and therefore may not address short-term hiring needs. Further,  officials from one Navy MTF stated they continue to face difficulty hiring  for positions allowed special salary rates, such as pharmacist and  registered nurse positions. Our 2017 review of federal agency use of  special payment authorities approved by OPM—such as special salary  rates—found that agencies reported that access to authorities had  positive effects—such as on staff retention and applicant quality—but had  few documented effectiveness assessments. DOD is also authorized to offer DOD health care personnel a number of  salary rates established for Veterans Health Administration (VHA)  personnel. For example, DOD established a civilian physicians and  dentists pay plan using this authority. However, officials stated concerns  about the rates’ usefulness. Senior officials from one Air Force hospital  noted that although the VHA salary levels are higher than the General Schedule levels that DOD typically offers, they may not be competitive  with the private sector. Moreover, senior officials from one Army MTF  expressed an interest in accessing VHA salary rates for additional  occupations because Army personnel often leave to work at a nearby  Veterans Affairs hospital for higher pay. In 2017, we reported on VHA  physician recruitment and retention strategies and officials from the six  VA medical centers in our review stated that physician salaries were often  below those offered by local private sector, academic, and some state  government employers. Contractor compensation. Senior officials from five of six MTFs stated  private sector contractor vendors face the same challenges as the  government regarding uncompetitive salaries. As a result, some contracts  have low fill rates or go unfilled. For example, senior officials at one Navy  MTF said one of its vendors has not been able to fill a clinical pharmacy  position for more than a year. Additionally, senior officials at the other  Navy MTF we spoke with stated that a vendor was not meeting its local  needs because the fill rate at their MTF is lower than the average fill rate  across all Navy MTFs, which is what the vendor is required to meet.  Further, senior officials at two of six MTFs—one Navy and one Air  Force—stated some of their vendors have attempted to fill positions by  sending multiple providers on a part-time basis to fill the equivalent of one  full-time position; they noted the part-time assignments are undesirable  and can affect the quality of care. FTE Targets and Hiring  Freezes Federal civilian FTE targets. Headquarters officials from each of the  military departments stated that federal civilian FTE targets are a barrier  to effective workforce mix management because they reduce flexibility in  utilizing the most efficient personnel type to accomplish the beneficiary  mission of the MHS. From fiscal years 2012 to 2017, OSD guidance  directed the military departments to manage to a federal civilian FTE  target. These targets were intended to prevent an increase in the size of  the federal civilian workforce, even when federal civilians’ performance of  work is most cost-effective. For example, Air Force headquarters officials  stated that due to the federal civilian FTE target, they generally default to  hiring contractor personnel when new personnel needs arise. Further, Air  Force headquarters officials stated they have not pursued in-sourcing of  some contracted functions even though such actions might result in cost  savings. The federal civilian FTE targets had varying effects on the operations of  the six MTF’s we spoke with. Senior officials at two of six MTFs—one  Navy and one Air Force—stated that they have not been adversely  affected by the federal civilian FTE targets because the relatively high  number of vacancies in their funded federal civilian positions means that  they never exceed their target. Conversely, officials at one Air Force MTF  stated they have considered hiring additional private sector contractor  services when they reach their allowed federal civilian FTEs. During the course of our review, DOD issued its National Defense  Business Operations Plan for Fiscal Years 2018 to 2022, which states  that it would discontinue the use of federal civilian FTE targets because  they acted as artificial and arbitrary constraints on the workforce, and  encouraged the military departments to utilize hiring flexibilities to identify  the most appropriate and economical personnel type to achieve their  mission. In 2002 we reported that federal hiring policies should, among  other things, avoid arbitrary full-time equivalent or other arbitrary  numerical goals. Federal civilian hiring freezes. Senior officials at five of six MTFs stated  that federal civilian hiring freezes adversely affect MTF operations. As  part of planning for sequestration in fiscal year 2013, DOD imposed hiring  freezes on federal civilian personnel. Further, there was a federal  civilian hiring freeze from January 2017 to April 2017. Senior officials from three of six MTFs reported that hiring freezes lower morale and  elongate the already lengthy hiring process, even when they are granted  waivers to continue to hire. Further, senior officials from one Army MTF  stated hiring freezes limit their ability to shape their workforce, and often  result in higher costs when they increase the size of their contracted  workforce in accordance with their needs. We reported in 2018 that  defense laboratory officials we surveyed identified government-wide  hiring freezes as a challenge to hiring candidates, stating that candidates  accepted other offers due to delays created by the freeze and that hiring  efforts continue to be adversely affected even after a freeze is lifted. These three key hiring challenges limit the military departments’ ability to  strategically consider the advantages of converting one source of support  to another, and limit their ability to hire the appropriate personnel type or  for contract vendors to fill positions. According to senior MTF officials,  these key hiring challenges and low fill rates in some areas can result in  personnel gaps that can adversely affect the operations of MTFs. When  personnel gaps arise, officials stated, military personnel often must work  additional hours or must be borrowed from other facilities. Senior officials  from one Navy MTF cited the example of a cost of about $16,000 in travel  expenses for the temporary transfer of an active duty nurse stationed in  Japan to work for a MTF in the United States for 3 months because the  MTF was not able to fill the position by other means. Additionally, senior  officials from one Air Force MTF noted that morale of its military staff is  negatively affected by extra hours and additional responsibilities placed  on them to ensure continued operations. Further, officials stated that personnel gaps can negatively affect care.  Due to concerns about patient safety, MTFs may decide to discontinue  some services at MTFs. 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.  Referring patients to the private sector can have secondary effects on  MTF operations, such as on hospital accreditations. Senior officials from  one Navy MTF noted that in the past fiscal year they had to refer patients  to private sector care after two hematology-oncology physicians resigned,  which may affect their hematology-oncology program’s accreditation.  Senior officials at the other Navy MTF stated that in the last fiscal year  they could not meet the minimum staffing standards for labor and delivery  staff and therefore sent patients to the TRICARE network. They noted  they are also having difficulty filling key administrative positions related to  quality control of laboratory services and are concerned about  maintaining their pathology program accreditation. Senior officials from MTFs reported varying fill rates for military and  civilian personnel, and for the contractor personnel provided by private  sector vendors. However, officials from the MTFs we spoke with stated  that fill rates may not illustrate the availability of personnel. For example,  officials stated that authorizations for military personnel are counted as  filled even when a servicemember is deployed and therefore not working  at the MTF. In addition, MTF officials stated that any on-board civilians  without corresponding authorizations inflate the civilian fill rate, resulting  in a fill rate of greater than 100 percent. In addition, DOD officials noted  that DOD pays for contracted services and does not directly employ  contractor personnel. Therefore, the fill rate for contractors represents  either the number of authorized FTEs in the individual contract or  positions filled by contactors noted on the MTF’s force planning  document, which could also result in fill rates of greater than 100 percent,  even as other positions remain unfilled. The MTFs that we spoke with  reported the following fill rates: Two Navy MTFs. The fill rates for military personnel, federal civilian  personnel, and funded positions designated for contracted services  were 79 percent, 81 percent, and 94 percent, respectively, at one  Navy MTF and 93 percent, 53 percent, and 62 percent, respectively,  at the other MTF. Two Air Force MTFs. The fill rates for military personnel, federal  civilian personnel, and funded positions designated for contracted  services were 98 percent, 86 percent, and 91 percent, respectively at  one Air Force MTF and 94 percent, 74 percent, and 90 percent,  respectively at the other MTF. Two Army MTFs. The fill rates for military personnel, federal civilian  personnel, and funded positions designated for contracted services  were 91 percent, 118 percent, and 87 percent, respectively at one  Army MTF. At the other MTF, the fill rate for military personnel fill  rate was 94 percent and for federal civilian personnel was 107  percent, but the MTF officials did not provide fill rate information for  positions designated for contracted services because there are no  corresponding authorizations on their force planning document. DOD has been taking some steps to attempt to address these key hiring  challenges. Specifically, DOD’s 2016 Strategic Workforce Plan included  steps DOD was taking to address personnel gaps, such as a targeted  recruitment program for critical skills, including 27 harder-to-fill medical  occupations. In 2018, DOD published a Human Capital Operating Plan  which states that it replaces the previously required Strategic Workforce  Plan, but DOD does not yet have a plan of action specific to the medical  professions. Further, DOD officials stated that components are  encouraged to consider developing their own human capital operating  plans. With regard to contracting, in response to a requirement in the  National Defense Authorization Act for Fiscal Year 2017, DOD issued a status report in January 2018 on the development of its acquisition  strategy for health care services at MTFs. The report notes that  contracting for health care services is fragmented, and the report outlines  DOD’s plan to move toward a single contract vehicle for health care  services and to establish metrics for the strategy, such as measurement  of contract fill rates. While these steps represent efforts to address these challenges,  responsibility for management of the federal civilian and contractor  workforces within the MHS will soon see significant changes. Specifically,  in December 2016, Congress directed the transfer of administrative  responsibility for MTFs from the military departments to the DHA.  Further, Congress amended the law in 2018 to specify that the transfer  should be completed by September 30, 2021. The law also states that  at each MTF, the Director of the DHA has the authority to determine total  workforce requirements, direct joint manning, and address personnel  staffing shortages, among other things. Although the DHA will soon begin to assume these responsibilities and  the challenges associated with them, a senior OASD(HA) official  responsible for human capital issues stated that the DHA currently has no  strategic total workforce plan, or similar document, to help ensure  execution of an appropriate workforce mix at its MTFs. 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. GAO’s key principles for effective strategic workforce  planning and applicable federal regulations have shown that addressing a  critical human capital challenge—such as closing or reducing personnel  gaps—requires tailored human capital strategies and tools and metrics by  which to monitor and evaluate progress toward reducing gaps. Although  many hiring challenges are longstanding government-wide issues, GAO’s  model of strategic human capital management states that agencies need  not wait for comprehensive civil service reform to modernize their human  capital approaches. In addition, according to OPM’s standards for  strategic workforce planning, human capital strategies should be  integrated with acquisition plans, among other things, such as DOD’s  acquisition strategy for health care services at MTFs. As the DHA finalizes its plans for assuming administrative control of  MTFs, senior leaders may find that they face the same challenges  reported by the military departments in executing an appropriate  workforce mix. DHA could mitigate these challenges to executing the  appropriate workforce mix in the MTFs by engaging in strategic workforce  planning, including tailored human capital strategies, tools, and metrics by  which to monitor and evaluate progress toward reducing gaps, and  integrating this planning with DOD’s acquisition strategy for health care  services at MTFs. The Military Departments  and DHA Have Not  Decided How Military  Personnel Will Meet  Operational and  Beneficiary Missions after  the Transfer of  Administrative  Responsibility for MTFs to  DHA The planned transfer of administrative responsibility for MTFs from the  military departments to the DHA may present challenges to DOD’s  management of military personnel. Specifically, the military departments  and DHA have not determined how military personnel will meet both the  operational and beneficiary missions of the MHS after the transfer of  administrative responsibility for MTFs to the DHA. Historically, each  military department has been responsible for managing its military  personnel to ensure it meets its operational mission and appropriately  staffs its MTFs, and the challenge of balancing these missions was the  responsibility of each respective military department. However, the  transfer of administrative responsibility for MTFs to the DHA will separate  these missions—the operational mission will be the responsibility of the  military departments, and the beneficiary mission will be the responsibility  of the DHA, with military personnel used to support both missions. The  plan for transfer of administrative responsibility for MTFs to the DHA  states that the military departments will retain ultimate control over  military personnel, who will work within the MTFs on a day-to-day basis to  maintain their readiness to provide operational medical care, while the  DHA will eventually assume responsibility for federal civilian and  contractor personnel and all other aspects of MTF management. DOD  officials stated that the planned transfer will allow the military departments  to focus their attention on readiness to provide operational medical care,  while the DHA will focus its attention on efficient management of  beneficiary health care operations. As a result of this separation of  missions, challenges in the management of military personnel could be  exacerbated by transfer of responsibility for achieving these missions to  separate organizations in the following three ways. First, DHA and the military departments have not clearly identified how  they will manage the assignment of military personnel to MTFs. The  implementation plan for transfer of administrative responsibility for MTFs  to the DHA states that the departments will continue to be responsible for  assignment of military personnel to MTFs. However, DOD’s stated desire  to place greater emphasis on the readiness mission may affect current  MTF staffing practices. For example, military department officials told us  that it is common practice to assign military personnel to locations that  face challenges in hiring federal civilian and contractor medical personnel  to maintain access to medical care in these locations. However, the  transfer implementation plan states that the departments will provide  military personnel to the MTFs only to the extent that the MTFs can  provide sufficient workload to maintain providers’ military medical  Knowledge, Skills, and Abilities (KSAs). KSAs are a metric for military  operational readiness that DOD has not yet finalized. Officials responsible  for planning the transfer of administrative responsibility for MTFs to the  DHA stated that the emphasis on fulfilling KSAs in the future may result in  concentrating military providers in larger MTFs, which can provide  opportunities for providers to fulfill KSAs. However, this change could  create a disadvantage for smaller facilities, which may not be able to  provide military providers with as much practice and already face  challenges in hiring federal civilian and contractor personnel. Second, DHA and the military departments have not clearly identified how  they will mitigate the effect of deployments of military medical personnel  on MTF operations. When medical personnel are deployed out of MTFs  to provide operational care, their absence can create a gap or reduction  in capability at the affected MTF, according to military department  officials. The military departments, prior to the transfer, manage  deployments and are responsible for ensuring appropriate staffing at the  MTFs in the absence of deployed personnel. Officials at all six of the  MTFs we visited cited challenges with mitigating the effect of  deployments on MTF operations. DOD has stated that after the transition,  there will be no barriers to the military departments’ access to personnel  for deployment, and has highlighted options for addressing staffing gaps,  such as using borrowed military personnel, contractors, or referral to the  TRICARE network. However, officials at all six of the MTFs we spoke with  stated that contracting for medical services was not sufficiently timely or  effective, and officials at one MTF noted that referral to the TRICARE  network was difficult in their area. According to officials within the MTFs of the National Capital Region,  which is directly managed by the DHA and not the military departments,  management of deployments and their adverse effect on hospital staffing  has been a challenge. For example, officials cited a period in the summer  of 2017 when, due to overlapping deployments across military  departments, 8 of 9 general surgeons at Fort Belvoir Community Hospital  in Virginia were simultaneously deployed, and patients had to be referred  to private providers within the TRICARE network or sent to Walter Reed  National Military Medical Center in Maryland. Although the military departments and the DHA have executed a  Memorandum of Agreement concerning coordination for service  personnel to fill scheduled deployments, this does not always prevent  gaps in medical specialties. For example, officials noted that requests for  volunteer deployments are not always vetted through NCR management.  Further, addressing these gaps can be challenging. Specifically, officials  cited difficulties in successfully contracting for medical services and  reported that requests for backfill support from the reserve components  has associated costs and is difficult to execute. Third, DHA and the military departments have not clearly identified how  they will manage changes to the size or composition of the active duty  medical workforce that affect workforce balance within MTFs. Since 2008,  the military departments have been prohibited from converting medical  positions designated for military personnel to positions that can be filled  by federal civilians—even when such conversions would result in cost  savings. Air Force headquarters officials noted that they have identified  more than 4,000 medical positions to review for possible conversion to  achieve cost savings, particularly in medical specialties with excess  military personnel, such as family practice and pharmacy. Air Force  officials previously identified 4,724 positions for conversion beginning in  fiscal year 2005, of which 1,449 were completed before the prohibition  was enacted. The Army planned to convert 4,340 military positions from  fiscal year 2006 through fiscal year 2011, of which 1,459 were completed  before the prohibition was enacted. The Army restored 165 of planned  conversions for fiscal year 2007, and reversed, or offset the remaining  through growth in the active duty medical force after the prohibition was  enacted. The National Defense Authorization Act for Fiscal Year 2017 allows for  the prohibition on such conversions to be lifted after DOD submits a  report that defines the military medical and dental requirements  necessary to meet operational medical force readiness requirements, and  lists the positions necessary to meet such requirements. However,  decisions on conversions taken by the departments could affect MTF  operations. Specifically, existing challenges with hiring federal civilian  personnel could create challenges with military-to-civilian conversions.  For example, DOD has stated that during the previous round of military to  federal civilian conversions, changes in local market conditions affected  the ability of the military departments to fill converted positions with  civilians in a timely fashion. Medical headquarters officials the Army  stated that they currently have no intention to use conversions if the  prohibition is lifted; Navy officials stated they currently do not plan to use  conversions since their military personnel requirements exceed their  authorizations. Senior officials from one Navy MTF we spoke with stated  that if conversions occurred, recruitment and retention challenges related  to hiring federal civilian employees would need to be addressed to ensure  such positions are filled. In addition, military department policies can affect workforce balance  within MTFs. Specifically, in its modeling for operational medical  personnel requirements, the Air Force includes a preference for  uniformed personnel to receive primary care from uniformed medical  personnel. Officials told us that this approach, known as the Critical Home  Station, is because Air Force leadership believes that performance of this  function by military personnel provides for increased accountability for  medical readiness. For example, senior officials from one Air Force MTF  stated they believe the policy is important for the Air Force to maintain  access to information about health factors that could render a  servicemember not medically qualified to deploy. Air Force medical  headquarters officials estimate that the policy results in 2,000 positons  reserved for military personnel that could be designated for federal civilian  or contractor performance. Leading practices for results-oriented government state that cooperating  federal agencies need to sustain and enhance their collaboration in  several ways, including the development of policies and procedures to  operate across agency boundaries and agreement on their respective  roles and responsibilities. However, planning for the transition by the  DHA and the military departments has not yet included development of  policies and procedures for management of military personnel and  agreement on specific roles and responsibilities for the military  departments and the DHA in this process. The MHS process for  collaborating across agency boundaries, known as MHS Governance,  emphasizes collaborative work in the management of the MHS. This  forum could provide an opportunity for the military departments and the  DHA to develop policies and procedures for management of military  personnel and agree on specific roles and responsibilities for the military  departments and the DHA in this process. Until DHA and the military  departments develop such policies and procedures and agrees on roles  and responsibilities, the MHS may continue to face a number of  challenges related to the transfer of administrative responsibility for MTFs  to the DHA. Conclusions Given the size of the MHS, its central importance to the success of DOD’s  mission, and its cost, having the right mix of military, federal civilian, and  contractor personnel providing medical care within MTFs and in deployed  operational settings should be a key priority for DOD leadership. While  the military departments have policies and procedures in place to assess  medical workforce mix in both settings, the shortcomings we have  highlighted present barriers to achieving an appropriate workforce mix.  Recently, such as in the 2018 National Defense Business Operations  Plan, DOD has emphasized the need to reassess who can most  efficiently perform all aspects of DOD’s mission. However, the military  departments’ planning processes for operational medical personnel  requirements continue to rely solely on military personnel, despite the use  of federal civilians and contractors in operational settings, and the military  departments have not developed full information on the cost of their  medical forces and incorporated such information into decision-making  processes about the mix of active and reserve component personnel.  Similarly, the transfer of administrative responsibility for MTFs to the DHA  represents an opportunity to reassess workforce mix at the MTFs.  However, long-standing challenges in the management of federal civilian  and contractor personnel, coupled with challenges related to the  management of medical personnel after the transfer, could overshadow  and cast doubt on the success of that reform. Without addressing the  concerns we have highlighted, DOD may miss the opportunity presented  by current transformation efforts in the MHS to ensure it has in place the  most cost-effective mix of personnel in its workforce to accomplish its  medical mission. Recommendations for  Executive Action We are making five recommendations to the Department of Defense. The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in coordination with the military departments,  perform an assessment of the suitability of federal civilian and contractor  personnel to provide operational medical care and incorporate the results  of the assessment into relevant policies, if warranted. (Recommendation  1) The Secretary of Defense should ensure that the Under Secretary of  Defense for Personnel and Readiness require consideration of cost when  making determinations regarding the mix of active and reserve  component medical personnel. (Recommendation 2) The Secretary of Defense should ensure that the Assistant Secretary of  Defense for Health Affairs, in collaboration with the Director of Cost  Assessment and Program Evaluation and the military departments,  develop full cost information for active and reserve component medical  personnel, and the military departments use that information in its  determinations regarding the mix of active and reserve component  medical personnel. (Recommendation 3) The Secretary of Defense should ensure that the Director of the Defense  Health Agency develop a strategic total workforce plan which includes,  among other things: (1) tailored human capital strategies, tools, and  metrics by which to monitor and evaluate progress toward reducing  personnel gaps, and; (2) integration of human capital strategies with  acquisition plans, such as DOD’s acquisition strategy for health care  services at DOD’s military treatment facilities. (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. DOD’s comments are reprinted  in appendix II. We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Under Secretary of Defense  for Personnel and Readiness, the Assistant Secretary of Defense for  Health Affairs, the Director of Cost Assessment and Program Evaluation,  the Director of the Defense Health Agency, and the Secretaries of the  Army, the Navy, and the Air Force. In addition, this report will be available  at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions regarding 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 III. Appendix I: Scope and Methodology To address the extent to which the military departments’ planning process  for operational medical personnel requirements have assessed the mix of  federal civilian, contractor, active and reserve medical personnel (i.e.  workforce mix), we compared the military departments’ efforts in planning  for operational medical personnel requirements to the Department of  Defense (DOD) and department-level policies and guidance on workforce  mix determination and identifying the full cost of its military medical  personnel. DOD Directive 1100.4 states that authorities should consider  all available sources when determining workforce mix. DOD Instruction  1100.22 directs the steps that workforce planning authorities must take in  planning for personnel requirements and emphasizes consideration of all  potential workforce sources and an accurate understanding of personnel  costs. We also reviewed related DOD documentation on identifying  military essential positons and the use of alternative workforces.  Specifically, DOD’s National Defense Business Operations Plan for fiscal  years 2018 through 2022 states that workforce rationalization strategies  include, among other things, reassessing military manpower allocations  for military essentiality and identifying functions and positions that are  commercial in nature that may be appropriately or efficiently delivered via  private sector support. Moreover, DOD’s 2017 Workforce Rationalization  Plan recognizes DOD’s civilians as an essential enabler of its mission  capabilities and operational readiness and noted that there are numerous  opportunities for the military departments, combatant commands, and  others to make well-reasoned adjustments to workforce mix. To determine the extent to which federal civilians and contractors were  deployed to provide medical care we reviewed federal civilian and  contractor deployment data from fiscal years 2013 through 2017. We analyzed data for this timeframe to enable us to identify deployments over  the last 5 years, and fiscal year 2017 was the most recent full fiscal year  of available data at the time of our review. To assess the reliability of  these data, we electronically tested the data to identify obvious problems  with completeness or accuracy and interviewed knowledgeable agency  officials about the data. We found the data to be limited in that the  deployment data may not be sufficiently reliable for identifying the  universe of deployments. However, we found the data to be sufficiently  reliable for the purposes of reporting that federal civilians and contractors  have been deployed to provide medical care. Further, we interviewed  officials from the Office of the Under Secretary of Defense for Personnel  and Readiness (USD(P&R)), Office of the Assistant Secretary of Defense  for Health Affairs (OASD(HA)), Defense Civilian Personnel Advisory  Service, the military departments, and selected combatant commands to  identify considerations and any challenges of using different personnel  categories as workforce alternatives for meeting operational medical  requirements. To determine the appropriate use of the active and reserve components  for DOD’s operational medical personnel military requirements, we  compared the military departments’ efforts in assessing their active and  reserve balance to DOD and department-level policies and guidance.  Specifically, in a 2013 DOD report issued in response to section 1080A of  the National Defense Authorization Act for Fiscal Year 2012, DOD  established five factors that play a key role in active and reserve  component balance decisions, including the cost of unit manning, training,  and equipping. According to the report, cost is often outweighed by other  factors when making active component and reserve component mix  decisions, but should always be considered in active component and  reserve component mix decisions. DOD Instruction 7041.04 has guidance  for military departments to use to identify the full cost of their active  component, federal civilian, and contractor workforces. 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 determine the mix of active and reserve component medical  personnel, we analyzed authorization data from the Health Manpower  and Personnel Data System for fiscal year 2017. We analyzed data for  fiscal year 2017 because this was the most recent year of available data  at the time of our review. To assess the reliability of these data, we  electronically tested the data to identify obvious problems with  completeness or accuracy and interviewed knowledgeable agency  officials about the data. We found the data to be sufficiently reliable for  reporting on the allocation of authorizations for 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.  We also reviewed the military departments’ efforts in planning, staffing,  and filling MTF requirements. We spoke with knowledgeable officials from  the Office of the USD(P&R), OASD(HA), DHA, and the military  departments and requested documentation related to how they oversee  or implement legal or policy requirements, such as DOD Instruction  1100.22’s manpower mix criteria, and the annual inventory of inherently  governmental and commercial activity. 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. To assess the reliability of these data, we compared them to  the information reported in the fiscal year 2017 Defense Health Program  justification estimates published in February 2018 to identify key  differences and interviewed knowledgeable agency officials about the  data. We found the data to be sufficiently reliable for the purposes of  describing workforce mix of military, federal civilian, and contractor  personnel within MTFs. To understand how policies and procedures to determine and execute an  appropriate workforce mix are implemented at MTFs, we interviewed  military department medical command or agency officials responsible for  implementing DOD total force policy. To better understand policy and  procedure implementation at MTFs we selected six MTFs - two each from  the Army, Navy, and Air Force - to allow a cross-section of views  concerning the management of the military departments’ workforce mix at  the MTFs and hiring conditions in different types of labor markets. The  two MTFs from each military department were selected based on  consideration of average daily patient load and MTF bed size, which we  obtained from the Defense Health Agency. For each MTF, we interviewed officials responsible for the leadership and  management of MTF personnel and operations and requested and  reviewed relevant documentation. We reviewed their responses, which  highlighted some challenges related to achieving an appropriate  workforce mix, and DOD’s plans for addressing these challenges. We  compared these to GAO’s key questions to assess agency reform efforts,  which note that strategic workforce planning should precede any staff  realignments or downsizing, and GAO’s key principles for effective  strategic workforce planning, which state that addressing a critical human  capital challenge—such as closing or reducing personnel gaps—requires  tailored human capital strategies and tools and metrics by which to  monitor and evaluate progress toward reducing gaps. We also reviewed  these plans in light of OPM’s standards for strategic workforce planning,  which note that human capital strategies should be integrated with  acquisition plans, among other things, such as DOD’s acquisition strategy  for health care services at MTFs. Finally, we requested from officials at  each MTF information on personnel inventory and authorizations to  understand their ability to fill military and civilian positions, and the  contract vendors’ ability to fill positions designated for contracted  services. We also reviewed how the planned transfer of administrative  responsibility for MTFs from the military departments to the DHA might  affect DOD management of military personnel within the MHS. To identify  (1) responsibilities of the military departments that may be transferred to  the DHA, and (2) challenges that may continue under the new organizational structure, we reviewed relevant documentation and  interviewed knowledgeable officials. To understand potential challenges  related to the assignment of military personnel to MTFs, we interviewed  military department officials responsible for the assignment of military  personnel. To identify how deployments affect MTF operations, if at all,  we interviewed officials responsible for the leadership and management  of MTF personnel and operations. Lastly, to understand how the military  departments manage the size and composition of the active duty medical  workforce, we requested documentation related to the development of  operational personnel requirements and interviewed knowledgeable  officials. We also reviewed previous efforts to alter the size or  composition of the active duty medical workforce, such as military to  civilian conversions. We compared DOD’s efforts to plan for these  challenges to leading practices for results-oriented government, which  state that cooperating federal agencies need to sustain and enhance their  collaboration in several ways, including the development of policies and  procedures to operate across agency boundaries and agreement on their  respective roles and responsibilities. We conducted this performance audit from September 2017 to November  2018 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. Appendix II: Comments from the Department  of Defense Appendix III: GAO Contact and Staff  Acknowledgments GAO Contact Staff  Acknowledgments In addition to the contact named above, Lori Atkinson, Assistant Director;  Tracy Barnes; Alexandra Gonzalez; Adam Howell-Smith; Kirsten Leikem;  Amie Lesser; Richard Powelson; Clarice Ransom; Stephanie Santoso;  Amber Sinclair, and John Van Schaik; made key contributions to this  report. Related GAO Products Military Personnel: Additional Actions Needed to Address Gaps in Military  Physician Specialties. GAO-18-77. Washington, D.C.: February 28, 2018. Defense Health Reform: Steps Taken to Plan the Transfer of the  Administration of the Military Treatment Facilities to the Defense Health  Agency, but Work Remains to Finalize the Plan. GAO-17-791R.  Washington, D.C.: September 29, 2017. Defense Health Care Reform: DOD Needs Further Analysis of the Size,  Readiness, and Efficiency of the Medical Force. GAO-16-820.  Washington, D.C.: September 21, 2016. Human Capital: Additional Steps Needed to Help Determine the Right  Size and Composition of DOD’s Total Workforce. GAO-13-470.  Washington, D.C.: May 29, 2013. Military Personnel: DOD Addressing Challenges in Iraq and Afghanistan  but Opportunities Exist to Enhance the Planning Process for Army  Medical Personnel Requirements. GAO-11-163. Washington, D.C.:  February 10, 2011. Military Personnel: Enhanced Collaboration and Process Improvements  Needed for Determining Military Treatment Facility Medical Personnel  Requirements. GAO-10-696. Washington, D.C.: July 29, 2010. Military Personnel: Status of Accession, Retention, and End Strength for  Military Medical Officers and Preliminary Observations Regarding  Accession and Retention Challenges. GAO-09-469R. Washington, D.C.:  April 16, 2009.
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. 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.