Defense Health Care: Collaboration and Criteria Needed For Sizing
Graduate Medical Education (Letter Report, 04/29/98, GAO/HEHS-98-121).

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

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

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-98-121
     TITLE:  Defense Health Care: Collaboration and Criteria Needed For 
             Sizing Graduate Medical Education
      DATE:  04/29/98
   SUBJECT:  Physicians
             Military personnel
             Medical education
             Graduate education
             Base closures
             Health care programs
             Military downsizing
             Military cost control
             Site selection
             Combat readiness
IDENTIFIER:  DOD TRICARE Program
             
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Cover
================================================================ COVER


Report to Congressional Committees

April 1998

DEFENSE HEALTH CARE -
COLLABORATION AND CRITERIA NEEDED
FOR SIZING GRADUATE MEDICAL
EDUCATION

GAO/HEHS-98-121

Defense Health Care

(101609)


Abbreviations
=============================================================== ABBREV

  BRAC - base realignment and closure
  DOD - Department of Defense
  GME - graduate medical education
  MEPC - Medical Education Policy Council
  THCSRR - Total Health Care Support Readiness Requirements

Letter
=============================================================== LETTER


B-278953

April 29, 1998

The Honorable Stephen E.  Buyer
Chairman
The Honorable Gene Taylor
Ranking Minority Member
Subcommittee on Military Personnel
Committee on National Security
House of Representatives

The Honorable Dirk Kempthorne
Chairman
The Honorable Max Cleland
Ranking Minority Member
Subcommittee on Personnel
Committee on Armed Services
United States Senate

Graduate medical education (GME) programs in military hospitals are
the Department of Defense's (DOD) main source of active duty
physicians to meet the wartime and peacetime care needs of its 8.2
million military and civilian beneficiaries.  In recent years, the
Army, Navy, and Air Force have sought to reduce GME enrollment as
their budgets, along with overall military personnel strength,
including the number of physicians, have declined.  Such GME
adjustments require care to ensure an appropriate balance between the
numbers and types of physician specialists in training, and thus not
militarily deployable, and the numbers of trained specialists
available for deployment.  As overall downsizing continues, the
services are finding that required GME reductions may entail closing
whole programs at selected facilities.  In early 1997, moreover, the
Navy Surgeon General attempted but was unsuccessful in closing
selected GME programs. 

In response to the Navy's experience, the Congress included a
requirement in the 1998 National Defense Authorization Act that we
review a Navy advisory council's recommendations for restructuring
Navy GME.\1 Specifically, we were to review recommendations for GME
closures at Bethesda Medical Center that the Navy Surgeon General
rejected in favor of closing the Portsmouth, Virginia, Medical
Center's GME programs.  Also, the National Security Committee's
Subcommittee on Military Personnel asked us to comparatively review
the Army's and the Air Force's GME closure activities.  In
discussions with cognizant congressional offices, we agreed to focus
our response to these requests on (1) why the Navy did not accept its
council's recommendations for Bethesda GME closures and why its other
closure attempts did not succeed, (2) whether the other services
already have faced or may face similar experiences, and (3) what
improvements may be needed if the services are to successfully make
and implement their GME sizing decisions.  The act prohibits the Navy
from restructuring its GME programs until we report on the issue. 

In doing our work, we interviewed officials and examined GME
requirements and resource records at DOD and service headquarters in
Washington, D.C.; Army and Air Force medical and personnel offices in
San Antonio, Texas; the Navy's Portsmouth, Virginia, Medical Center;
the Army's El Paso, Texas, Medical Center; and DOD's Washington,
D.C., and San Antonio regional managed care offices.  We reviewed the
guidance, GME program data, and processes bearing on recent GME
closure decisions and also broader DOD initiatives' potential effects
on GME.  While we did not specifically review the services' sizing
models designed to adjust military medical forces to meet readiness
requirements, we obtained status information on DOD's efforts to
standardize their use.  Appendix I details our work's scope and
methodology.  We conducted our work between September 1997 and March
1998 in accordance with generally accepted government auditing
standards. 


--------------------
\1 P.L.  105-85, sec.  748, Nov.  18, 1997. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

In early 1997, the Navy Surgeon General decided to eliminate 162 GME
positions to comply with lower projected wartime requirements and
with DOD restrictions on the ratio of physicians in training to those
deployable.  A Navy advisory council, lacking specific guidance but
responding to the Navy Surgeon General's indications that GME should
occur where active duty personnel are concentrated, recommended that
most such training be dropped at the Bethesda Medical Center. 
Bethesda was recommended rather than the Navy's other major centers
in Portsmouth, Virginia, and San Diego, California, where many active
duty personnel are located.  The Navy Surgeon General, however,
instead decided to close some of the Navy's Portsmouth Medical
Center's programs following a then-newly-
discussed agreement among DOD and the services' surgeons general to
concentrate GME in four geographic locations that included Bethesda
and San Diego but not Portsmouth.  Lacking site selection guidance
and needed communication, the Navy council developed and submitted
its recommendations to the Surgeon General without taking account of
the agreement, which has never been formalized or acted on by the
other services. 

When announced, the Portsmouth closure decision surprised Navy
command and medical center officials there, as well as local
congressional representatives.  Publicized arguments ensued that
Portsmouth was as advantageous as Bethesda for concentrating GME and
that losing Portsmouth's GME would reduce trainee-provided health
care to active duty personnel and other beneficiaries and would harm
Naval readiness.  Although it was unsuccessful, the Surgeon General's
office tried justifying the decision and later withdrew it for
further study.  At about the same time, the Surgeon General made and
later reversed a decision to close a Bremerton, Washington, GME
program, similarly acting against advisory council recommendations
and meeting resistance from those affected by but not privy to the
decision. 

Shortly thereafter and for the same ends, the Army Surgeon General's
office sought to eliminate the 64 GME positions at the William
Beaumont Medical Center in El Paso, Texas, also without site
selection guidance and likewise failing to involve those who were
affected.  When it was announced, the closure proposal was firmly
resisted and challenged by medical center and line command officials
and a local congressional representative.  In response, the Surgeon
General's office did more site choice analysis, but the decision was
ultimately deferred. 

While the Air Force also foresees the need for GME program closures,
it has not yet attempted to make them.  But in the absence of closure
policies and criteria and judging from the Navy's and Army's closure
attempt experiences, we have no reason to believe that the Air Force
would be any more successful in bringing about required GME program
adjustments. 

In our view, DOD and the services need commonly accepted guidance and
criteria for choosing GME reduction and closure sites and for
including those affected in the decisions.  DOD, the services, and we
cannot appropriately judge the merits of closing one GME program over
another in the absence of criteria on such matters as what factors to
weigh in deciding which programs to close, including who should
participate when and how in the decision.  A decision framework would
also need to account for other DOD initiatives' effects on GME, such
as the cost-cutting emphasis under DOD's nationwide managed care
program called TRICARE, a recent management reorganization, and
efforts to standardize the services' somewhat differing applications
of their medical force sizing models.  And, while not a direct
parallel to DOD GME with its readiness dimension, private sector
medical schools and hospitals have been downsizing their GME programs
and in doing so have documented success factors that may provide a
useful reference for DOD in developing guidance for its future sizing
efforts.\2


--------------------
\2 Reaching Informed Institutional Decisions About Graduate Medical
Education Program Size, Group on Resident Affairs, Work Group on GME
Sizing, Association of American Medical Colleges, Oct.  1997. 


   BACKGROUND
------------------------------------------------------------ Letter :2

DOD's health care system, costing over $15 billion annually, has the
dual mission of providing medical care to 1.6 million military
personnel during war or other military operations and offering health
care to 6.6 million military dependents and retirees.  Most care is
provided in about 600 military medical facilities worldwide,
including medical centers, community hospitals, and clinics.  The
system employs about 100,000 active duty military personnel. 

Military medical personnel include about 12,275 physicians, of whom
about 3,000 are in GME programs in military facilities.\3 The
services view GME as the primary pipeline for developing and
maintaining the required mix of medical provider skills to meet
wartime and peacetime care needs.  They also view GME as important to
successful physician recruitment and retention.  GME includes
internships, residencies, and fellowships enabling medical school
graduates to become specialists in such areas as internal medicine,
radiology, and general surgery.  Some of the military personnel GME
training is done in civilian hospitals.  The cost of GME is unclear. 
In May 1997, the DOD Inspector General reported that GME costs exceed
$125 million annually, with per-student costs ranging from about
$20,000 to $100,000, but reported also that military facilities did
not accurately account for such costs.\4

DOD's Office of Health Affairs is responsible for developing overall
GME policy guidance and promoting GME program coordination and
integration among the services.  The services are responsible for
ensuring that GME goals are met and for individual GME programs. 
Civilian boards review DOD's GME programs to ensure that they meet
such medical standards as minimum numbers of trainees per program and
can thus be accredited.  GME is taught at the services' facilities
throughout the United States, as shown in figure 1. 

   Figure 1:  Locations of Air
   Force, Army, and Navy
   Facilities Providing GME

   (See figure in printed
   edition.)



   (See figure in printed
   edition.)

Several DOD policies directly affect the services' GME program size,
locations, and specialty types.  In 1996, for example, DOD issued a
requirement that medical force levels including GME trainee numbers
be linked to each service's wartime and operational support
requirements.\5 This was a major departure from when each service did
as much GME training as it had capacity for or when it trained to the
prior year's level.  DOD also defined GME trainees as nondeployable
unless a full mobilization state has been reached.\6 Deploying
trainees would disrupt the specialty physician pipeline and would
likely result in lost GME program accreditation.  Thus, as defined,
about 25 percent of active duty physicians are not deployable.  A
1994 DOD strategic plan set forth the following added GME rightsizing
principles: 

  -- Base realignment and closure (BRAC) 1995 would determine whether
     further sites conducting GME training will close.\7

  -- GME programs having no new trainees for 2 years are to be phased
     out. 

  -- Duplicate Washington, D.C., and San Antonio, Texas, GME programs
     should be integrated to the extent possible. 

  -- The number of GME trainees in DOD medical facilities should not
     exceed their aggregate fiscal year 1994 proportion of all
     active-duty physicians. 

In response to the 1994 plan, BRAC 1995 identified two hospitals for
closure that had GME programs, thus eliminating 177 GME positions. 
But BRAC legislative authority has expired, and any such future
authority is uncertain.  Also, ending programs lacking new trainees
has resulted in few position reductions, according to Health Affairs
officials.  And the Washington, D.C., and San Antonio GME program
integrations have also produced few trainee reductions, while no
other GME locations appear to be susceptible to such integration. 

Maintaining a maximum ratio of GME trainees to active duty physicians
is referred to as DOD's "25 percent policy." The aim is a proper mix
of experienced specialists, supplemented by the flow of newly trained
specialists needed to maintain that mix.  The services' actual GME
percentages vary slightly, but in total they equal about 25 percent
of active duty physicians. 

In the past, the GME ratio was met through BRAC actions and by
reducing GME without closing programs, but DOD and service officials
now agree that GME programs have been cut to levels below which
accreditation would be lost.  Thus, rather than basing GME size on
training capacity, the services are shifting toward basing their
reductions of GME on wartime requirements.  Beyond trimming programs,
moreover, the services are now seeking to close GME programs in
specific locations. 


--------------------
\3 As of July 1997, the Army had 1,297 GME trainees, the Navy had
881, and the Air Force had 819 in military facilities. 

\4 Reporting Graduate Medical Education Costs, DOD Office of the
Inspector General, Report 97-147, May 23, 1997. 

\5 Operational support here refers to all the medical missions
outside the military hospital, including humanitarian missions,
readiness training, and hospital ship and deployable unit
assignments, often outside the United States. 

\6 There are five mobilization levels--Selective, Presidential
Selected Reserve Call-Up, Partial, Full, and Total.  Essentially,
reserve forces would be mobilized before most GME trainees are
deployed. 

\7 This was the fourth in a series of military base closures and
realignments made by the independent Defense Base Closure and
Realignment Commission, which convened in 1988, 1991, 1993, and 1995
and was subsequently disbanded. 


   NAVY UNSUCCESSFULLY ATTEMPTS
   GME CLOSURES AT TWO LOCATIONS
------------------------------------------------------------ Letter :3

The Navy Surgeon General's GME closure attempts at the Portsmouth,
Virginia, and Bremerton, Washington, medical facilities would have
made far larger trainee reductions than any such prior Navy efforts
had made.  But the closure decisions were withdrawn when those
affected strongly objected.  Clearly at issue was (1) the guidance
that the Navy had followed in making the closure decisions, (2)
whether DOD had properly deliberated and agreed upon the decisions,
and (3) whether those who were affected both within and outside the
Navy were aware of the bases for the decisions and whether they had
been consulted when the decisions were being made.  DOD's lack of a
policy framework for formulating and implementing such decisions will
likely spawn continued resistance and thwart the Navy's and other
services' attempts to reduce GME positions when they are no longer
needed to meet wartime needs. 


      SURGEON GENERAL DIRECTS GME
      REDUCTIONS
---------------------------------------------------------- Letter :3.1

The Navy's GME closure efforts began in November 1996.  The Navy
Surgeon General concluded that the then-current military force
downsizing and DOD policy necessitated reducing GME training--such
that GME training would be limited to projected wartime requirements. 
On November 5, 1996, the Navy Surgeon General directed his advisers,
the Navy Medical Education Policy Council (MEPC), to recommend
appropriate GME training reductions, and this effort resulted in
targeted reductions of 162 positions, or 16 percent. 

In February 1997, the MEPC recommended making most of the GME
reductions by closing the Navy's Bethesda Medical Center's programs
while preserving GME at the Navy's other major centers at San Diego
and Portsmouth.\8 Lacking specific guidance on how to select closure
sites, the MEPC primarily focused on meeting the Navy sizing model's
needed medical specialist estimates and complying with the Surgeon
General's past statements about the importance of having GME where
the active duty personnel are concentrated--which today is in San
Diego and Portsmouth.  Records indicate that MEPC considered such
other factors as civilian GME accreditation standards and the
population, particularly active duty, to be served but did not
comparatively analyze how well the areas' available patient mix would
support GME--believing that Bethesda and Portsmouth were more than
sufficient on both scores.  While the MEPC weighed the potentially
adverse effects of closing Bethesda's GME programs on the GME
integration efforts, it concluded that preserving GME at Portsmouth
and San Diego, where active duty personnel are more concentrated, was
still preferable.  Otherwise, the MEPC viewed essentially all current
GME programs to be of equal merit. 


--------------------
\8 The Navy has GME programs also at Bremerton, Camp Pendleton,
Jacksonville, and Pensacola, although these are not major programs. 


      SURGEON GENERAL REJECTS
      COUNCIL'S RECOMMENDATIONS
---------------------------------------------------------- Letter :3.2

Notwithstanding the MEPC's recommendations for closing GME programs
at Bethesda, the Navy Surgeon General decided to close programs at
Portsmouth.  The Surgeon General informed the MEPC that his decision
resulted from an agreement made the previous week among Health
Affairs and the surgeons general that the national capital area,
including the Bethesda center, was to be one of four areas where the
services would begin concentrating GME.  Other such areas would be
San Antonio, San Diego, and Madigan Army Medical Center near Tacoma,
Washington. 

In further justifying his decision, the Surgeon General later
announced that integrated national capital area GME programs would be
maintained.  The Surgeon General told us that while the MEPC had
acted in the Navy's interests, broader DOD interests were also at
stake.  Moreover, about 5 months after announcing the Portsmouth GME
closure decision, the Navy Surgeon General's office completed a study
of health care demographics and workload covering the Bethesda, San
Diego, and Portsmouth areas, where it has major health care
concentrations.  That study concluded that, on the basis of
population, workload, and other factors, GME should be preserved at
Bethesda and San Diego rather than Portsmouth. 

Along with his Portsmouth GME closure decision, the Surgeon General
announced plans to close the Bremerton, Washington, naval hospital's
GME family practice program.  But the MEPC had specifically
recommended against family practice program closures, concluding that
such residencies were needed services.  The Surgeon General, however,
had opted for closure based on the Bremerton program's proximity to
the Madigan Army Medical Center's GME family practice--a key factor
that the MEPC did not consider. 


      NO AGREEMENT ON SITE
      SELECTION CRITERIA OR
      COLLABORATION AMONG THOSE
      AFFECTED
---------------------------------------------------------- Letter :3.3

Surprised by the Portsmouth decision, medical center officials and
their supporters, including a local active duty forces commander and
congressional members, disagreed with the Navy's basis for the
Portsmouth GME closure decision, arguing that GME trainee losses
would reduce services to active duty personnel and their dependents
and other beneficiaries and would harm readiness.  The Surgeon
General's office responded that it would monitor the effect on
Portsmouth's workload and would add resources if needed.  Portsmouth
Medical Center officials also argued that their center was as rich a
GME environment as any of the four locations apparently selected for
GME concentration.  Taking particular issue with Navy study findings
supporting Bethesda, Portsmouth officials told us that they have
comparable or better facilities, workload, patient mix, and other GME
support advantages.  MEPC officials told us that while both locations
have more than enough to support GME, Bethesda has the greater
workload for supporting GME.  And while the Surgeon General agreed
that Portsmouth is an attractive GME environment, he told us that
Bethesda is preferable because of greater available population and
patient mix and the overriding need to continue the national capital
area GME program integration efforts. 

Regarding the Surgeon General's reliance on the apparent agreement
for a four-area GME concentration, Health Affairs officials told us
that such an agreement was not made formal or otherwise published. 
Rather, these officials said the policy aim now is for the services
to size their GME programs by requirements-driven analyses rather
than by dictating some fixed number of GME centers.  Nonetheless,
they said that in today's environment having perhaps three to five
GME teaching centers with populations and other characteristics best
supporting GME would be a worthwhile, overall program outcome. 


      THOSE AFFECTED NOT PRIVY TO
      CLOSURE DECISIONS
---------------------------------------------------------- Letter :3.4

Local Portsmouth officials were not included in or adequately
informed about the Navy Surgeon General's GME closure decision, and
thus they were surprised by it and strongly resisted it.  The local
Navy command authorities, for example, learned of the decision upon
its being made public, which, as Health Affairs officials told us,
increased the difficulty of overcoming their objections.  While the
Surgeon General's office later offered clarifications and
reassurances about the decision, the initial impressions were not
overcome.  Paralleling this outcome was the Navy's announcement of
the Bremerton family practice GME closure.  Along with local
resistance came local publicity and misunderstanding that the family
practice clinic would be closed. 

Health Affairs officials told us that while the facilities generally
know that GME must be downsized, those affected, regardless of the
service or medical center targeted, will object.  The officials also
agreed that the communication of such GME decisions has been
inadequate but must be delivered convincingly to those within the
services who are affected, including line commands, as well as to
beneficiary groups and affected congressional members, since such
decisions affect them just as BRAC decisions do. 


      CLOSURE DECISIONS SUSPENDED
---------------------------------------------------------- Letter :3.5

In April 1997, while still trying to reassure all concerned, the Navy
suspended its Portsmouth GME closure decision pending the outcome of
a then-in-progress DOD-wide quadrennial defense review and further
Navy analysis.\9 The Navy expected the quadrennial review's results
to add GME reduction pressure but, as DOD reported in May 1997, it
did not.  And the Navy's further analysis, completed in July 1997,
supported the Portsmouth closure.  But the 1998 National Defense
Authorization Act prohibited the Navy from making any GME changes
until we complete our review. 

As with the general response at Portsmouth, those affected locally
objected to the decision to close Bremerton's family practice GME
program.  They argued that the Navy significantly lacked such
specialists and that Bremerton's health care would be markedly
reduced with the loss of GME trainees.  Initially offering
reassurances about maintaining Bremerton's health care levels, the
Surgeon General eventually deferred the decision--which occurred at
about the same time as he deferred the Portsmouth GME decision. 
However, the Surgeon General still considered the reasons for closing
Bremerton's family practice GME to be valid. 


--------------------
\9 The quadrennial defense review is required by the National Defense
Authorization Act for fiscal year 1997 and is designed by DOD to
comprehensively review America's defense needs through 2015 and
provide a blueprint for a strategy-based, balanced, and affordable
defense program. 


   ARMY'S CLOSURE ATTEMPT ALSO
   UNSUCCESSFUL
------------------------------------------------------------ Letter :4

While the Army's GME sizing efforts--and the Air Force's for that
matter--are independent of the Navy's, the services are subject to
the same general policies and downsizing pressures.  A few months
after the Navy's closure attempts, the Army Surgeon General acted on
an internal recommendation to close all remaining GME programs at the
Army's William Beaumont Medical Center in El Paso.  A representative
from the Surgeon General's office told us that the apparent proposal
to concentrate GME in four geographic locations was not a factor in
choosing William Beaumont.  The official told us that essentially the
Army projected a need to eliminate about 50 GME trainee positions,
and William Beaumont's remaining 64 positions met that requirement. 

Like the Navy's efforts, the Army's closure attempt was met with
surprise and resistance by medical center, line command, and
congressional representatives, who took issue with the decision's
basis.  The Army decided not to proceed with the closures, but like
the Navy it still faces the need to close programs to achieve GME
reductions. 

Upon learning that the William Beaumont closure decision was based
almost entirely on the need to decrease GME trainee numbers to an
extent that the Beaumont numbers would meet, medical center officials
argued that the basis was arbitrary and unfair and that they had
already scaled back their GME programs.  Medical center officials and
their local supporters argued that the care level for active duty
personnel and their dependents and other beneficiaries in El Paso's
medically underserved community would be devastated and that most El
Paso physicians trained in certain specialties are at William
Beaumont.  The officials also argued that when a military hospital
loses its GME training, either the service relocates its best
teaching specialists or civilian markets attract them away.  An Army
Surgeon General's office representative told us that while the plan
was to redistribute William Beaumont teaching faculty to other
locations, the center's full patient care capability was to be
maintained. 

Like the Navy, moreover, the Army had not involved those most
directly affected by their closure deliberations in the initial
decision process.  And after William Beaumont officials and a local
congressional member appealed for the decision's reconsideration, the
Army conducted further analysis of such factors as patient
demographics, workload, and quality indicators among the Army's
teaching centers and GME programs but then suspended GME reduction
decisions for the coming training year. 


   AIR FORCE SOON TO CONFRONT GME
   PROGRAM CLOSURES
------------------------------------------------------------ Letter :5

The Air Force has not recently attempted major GME program closures. 
But it has been gradually reducing GME trainee numbers in ongoing
programs, and soon it too will need to close programs to comply with
wartime sizing requirements.  The Air Force is subject to the same
general closure policies, and we believe that its future attempts to
formulate, communicate, and sustain major GME closure decisions will
be as controversial as the Navy's and Army's recent experiences.  Air
Force officials told us that they are uncertain how such future
reduction processes will work. 

Air Force officials told us that if future GME closures were driven
by the four GME geographic centers concept, the Air Force would stand
to lose one-third of its programs--including all programs in certain
medical specialties.  These officials also told us that they were
unaware of any formal policy on the four GME center approach. 


   IMPROVEMENTS NEEDED TO
   FACILITATE GME SIZING DECISIONS
------------------------------------------------------------ Letter :6

The Navy's and Army's recent attempts to reduce their GME programs
were resisted by those who were affected, and they were otherwise
unsuccessful because DOD and the services lack accepted criteria on
such matters as what factors to weigh in deciding which programs to
close, including who should participate when and how in the
decisions.  In the absence of such criteria, DOD, the services, and
we cannot appropriately judge the merits of closing one GME program
rather than another.  Such criteria would also need to account for
other DOD initiatives' possible effects on GME; developing a
framework for the criteria might be facilitated by DOD's review of
lessons learned with private sector GME programs. 


      OTHER DOD HEALTH CARE
      INITIATIVES AFFECT GME
---------------------------------------------------------- Letter :6.1

The services' GME decisions can be affected by other DOD initiatives
that have to be taken into account for the GME reduction process to
work effectively.  For example, DOD has two studies that could affect
GME's size and location.  One is an ongoing, long overdue study of
the medical personnel required to meet wartime requirements, commonly
referred to as the 733 Update, originally scheduled for completion by
the end of March 1996.  The other is the Defense Reform Initiative,
announced in November 1997, that recommended reorganizing the DOD
health care program.  Related actions are expected to strengthen
program oversight and thus will likely affect the way GME decisions
are guided and made.  Another influence on GME is the nationwide
implementation of TRICARE, DOD's managed health care program. 
TRICARE requires military hospitals to be more cost effective, focus
on primary care, and share the care workload with support
contractors.  Such health care management shifts under TRICARE may
reduce funding and, according to DOD officials, reduce or otherwise
change the workload support for military facilities' GME. 

Further, DOD and the services are engaged in joint efforts toward
more integrated GME management, including collective oversight over
DOD's GME strategic plan, joint evaluation of GME applicants, and
planned efforts to consolidate GME administrative functions.  Also,
DOD is working toward standardizing the application of medical force
sizing models.  In 1996, we reported that while the services'
respective modeling approaches to estimating medical strength
requirements appeared to be reasonable, the models' results were
largely affected by input data and judgmentally assigned values and
assumptions.\10 Because the services differ somewhat in their
modeling applications, DOD is examining and seeking to reconcile the
differences--such as the relative effects of the Army's inclusion of
a "peacetime mission" component that the other services' models do
not include.  Differences in sizing model applications are also
expected to be addressed in the 733 Update report.  (Appendix II
provides more information on the services' models.)


--------------------
\10 Wartime Medical Care:  Personnel Requirements Still Not Resolved
(GAO/NSIAD-96-173, June 1996). 


      PARALLELS IN PRIVATE SECTOR
      GME DOWNSIZING
---------------------------------------------------------- Letter :6.2

The private medical sector has faced and continues to face the need
to reduce, close, or otherwise modify its GME programs at medical
schools and hospitals.  Growth in managed care, physician oversupply,
care delivery changes, and reduced funding to support civilian GME
have altered the demands on GME.  In October 1997, an Association of
American Medical Colleges workgroup representing more than 140
medical schools and 400 major teaching hospitals and health systems
published a resource document to assist teaching hospitals and
medical schools in developing institution-specific approaches to
analyzing and, if need be, modifying their GME programs. 

Synthesizing case studies and best practices, the work group
identified a number of elements it termed "critical success factors"
for rightsizing GME programs that we believe also have general
applicability for future DOD GME sizing efforts.  The factors include

  -- starting the GME resizing process well in advance of a critical
     need to reduce the number of residents;

  -- establishing clear guiding principles and ground rules;

  -- ensuring a proper time period for the resizing;

  -- securing top management's support, mindful that appropriate
     information to make a case for resizing can enhance the plan's
     acceptance;

  -- ensuring an inclusive process to minimize anxiety and identify
     and address concerns;

  -- affirming an institution's commitment to residents currently in
     training;

  -- assessing the financial effect of the resizing; and

  -- reengineering an institution's patient care processes where
     significant reductions in residents will occur. 

The work group also pointed out that a resizing effort's success
depends largely on minimizing its effects on patient care and fully
engaging the institution's leaders in the decisions. 


   CONCLUSIONS
------------------------------------------------------------ Letter :7

To attain DOD's overall GME policy goal of training to wartime
requirements, the services need the ability to make GME reductions
now and in the future.  Recent Navy and Army GME program closure
efforts, however, have not been successful, and the Air Force may
face similar problems when it attempts closures. 

DOD and the services lack policy guidance and criteria governing site
and program selection, including collaboration among decision makers
and those affected.  In deliberating closure alternatives, for
example, the Navy's MEPC did not know that (1) a change in position
had occurred on preserving GME where active duty personnel are
concentrated, (2) ongoing GME integration efforts were to be
preserved, (3) there apparently were to be only four GME
concentration centers, or (4) study results would be produced later
in support of either Bethesda or Portsmouth.  Along with disputes
about decision criteria, a key omission in the Navy's and Army's
closure attempts was that of not involving medical and line
commanders and others most directly affected by the decisions. 
Unsuccessful closure efforts dissatisfy those making and affected by
the decisions and reduce the credibility of the process but they also
may result in too many GME trainees, who are not readily deployable,
and too few deployable physicians ready when needed. 

Thus, we believe that with commonly accepted GME sizing criteria, DOD
and the services could make the program consolidations and closures
needed to meet readiness goals.  And we believe DOD and the services
should have an opportunity to collaboratively develop and implement
the criteria.  But because the programs are highly prized and
protected by the service hospitals and areas that have them,
achieving criteria and closure decision agreement may not be easy. 
Moreover, if unsurmountable differences surface in developing or
later applying the criteria, DOD may need to resort to forming a
group independent of it and the services tasked with developing
criteria or recommending and overseeing the implementation of
specific closure or consolidation decisions. 

Other DOD initiatives, including TRICARE, ongoing sizing studies, and
medical modeling application differences can bear on GME decisions,
and they need to be taken into account in the development of GME
program closure guidance for the closure process to be effective.  In
this regard, the Association of American Medical Colleges study of
critical success factors in GME resizing efforts could prove helpful
to DOD in its future resizing activities, particularly with respect
to establishing downsizing principles and ground rules, securing top
management support, and ensuring the inclusion of all who are
affected. 


   RECOMMENDATIONS
------------------------------------------------------------ Letter :8

We recommend that the Secretary of Defense direct the Assistant
Secretary of Defense for Health Affairs and the services' surgeons
general to collaboratively

  -- develop GME closure policy guidance and implementing criteria
     and processes covering such matters as key factors in
     identifying and winnowing potential sites, how to project and
     mitigate potentially adverse effects on beneficiary health care
     and readiness, how and when to involve those affected in the
     services and local areas in the decision-making process, how to
     reach program closure agreement, and how to communicate and
     implement the resulting decisions;

  -- provide in the guidance for the potential effects of such DOD
     and service initiatives as TRICARE, with its emphasis on cost
     control and primary care, that can affect GME decisions; and

  -- develop, obtain agreement on, and publish such policy guidance
     before any further GME closure decisions are made. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :9

In its written comments on a draft of this report, DOD agreed with
the report and its recommendations, characterizing our work as
objective in addressing the aborted GME closure attempts and the need
for clear downsizing criteria.  DOD stated, without further
elaborating, that the Navy and Air Force also concurred with the
report and recommendations but that the Army did not.  Nonetheless,
DOD stated that Health Affairs would develop a draft DOD directive
providing GME program closure and consolidation guidance that takes
into account managed care exigencies.  DOD and the Navy, Air Force,
and Army would be bound by such a directive once it is made final. 

We continue to believe that with commonly accepted GME sizing
criteria, DOD and the services could make the program consolidations
and closures needed to meet readiness goals.  And we continue to
believe that DOD and the services should have an opportunity to
collaboratively develop and implement the criteria.  But, as
exemplified by the Army's singular nonconcurrence with our
recommendations, getting agreement on the criteria and implementing
closure decisions likely will not be easy.  The programs are highly
prized and hence protected by the service hospitals and areas that
have them.  Thus, in the event that insurmountable differences
surface in developing or later applying the criteria, DOD may need to
resort to forming a body independent of it and the services tasked
with developing criteria or recommending and overseeing the
implementation of specific closure or consolidation decisions.  We
have added this matter to the report's conclusions section. 


---------------------------------------------------------- Letter :9.1

We are sending copies of this report to the Secretary of Defense and
will make copies available to others upon request. 

Please contact me at (202) 512-7101 or Dan Brier, Assistant Director,
at (202) 512-6803 if you or your staff have any questions concerning
this report.  Other GAO staff who made contributions to this report
are Elkins Cox, Beverly Brooks-Hall, and Allan Richardson. 

Stephen P.  Backhus
Director, Veterans' Affairs and
 Military Health Care Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

To assess the services' experiences in downsizing their graduate
medical education (GME) programs, particularly the Navy's
experiences, we examined the role of the Navy Medical Education
Policy Council (MEPC) and the guidance and data the MEPC considered,
evidence of the Navy's need for GME reductions and of the expected
advantages and disadvantages of closing GME programs at one location
versus another, and evidence that the Navy can still achieve needed
GME reductions in ways that comply with DOD guidance and that
overcome the kinds of objections raised in their recent closure
attempts.  For comparison, we examined comparable guidance,
processes, and data used by the other services in their GME
decisions.  Information sources included Department of Defense (DOD)
Health Affairs, the MEPC, the Navy Surgeon General's office, and
other cognizant organizations within the Navy, along with comparable
units in the other services. 

We interviewed (1) representatives of the Navy MEPC; (2) other Navy
officials responsible for sizing and managing GME; (3) Health Affairs
officials who provide GME guidance and oversight; (4) officials of
the other services in Washington, D.C., and San Antonio, Texas, who
direct and coordinate GME policy and programs; (5) officials at
selected medical centers--particularly the Navy center in Portsmouth
and the Army center in El Paso--where recent GME sizing decisions
have become an issue; and (6) officials of DOD's TRICARE Northeast
and Southwest regions, headquartered in Washington, D.C., and San
Antonio, which also included officials of military medical centers in
those areas.  We also reviewed their policy statements, briefing
documents on GME requirements, data on population and workload,
studies of GME placement, and other records and reports. 

We evaluated the Navy council's recommendations and subsequent GME
sizing decisions by the Navy Surgeon General in light of available
policy guidance, relevant available data, and other influential
factors that were or should have been considered.  We compared the
Navy's GME approach to decisions with that of the other services for
possible lessons from successful efforts and for any common problems
that need to be solved for all the services.  We also considered the
effects on GME of larger DOD initiatives, including the quadrennial
defense review, the Defense Reform Initiative, update of the 733
study, and managed care under TRICARE, as well as the services' use
of different sizing models to determine overall military medical
readiness requirements, including GME.  While we noted differences of
opinion about the application of the overall sizing models, resolving
those differences was beyond the scope of our work; the differences
are expected to be addressed in the update of the 733 study. 

We also researched efforts by private sector medical schools and
hospitals to alter the size of their GME programs, including a recent
study by the Association of American Medical Colleges, representing
medical schools and teaching hospitals, including the Department of
Veterans Affairs medical centers. 


SERVICES' USE OF MILITARY MEDICAL
FORCE SIZING MODELS
========================================================== Appendix II

Each service has its own sizing model for adjusting military medical
forces to meet its requirements.  Health Affairs offers a sizing
model also and has been promoting a more standardized sizing approach
for the services.  However, while the models can reveal overall
medical force requirements, they do not indicate where medical forces
should be located or where GME training should be done. 


   THE NAVY'S MODEL
-------------------------------------------------------- Appendix II:1

In response to budgetary and legislative pressures to properly size
Navy medical force structure, the Navy Surgeon General completed a
requirements model in March 1994, called Total Health Care Support
Readiness Requirements (THCSRR), to determine and project its active
duty medical force readiness requirements.  In November 1996, the
Surgeon General decided to apply THCSRR, which resulted in attempts
to significantly reduce GME. 

The THCSRR model defines readiness requirements as supporting three
missions, including (1) a wartime mission meeting the demands of two
nearly simultaneous major regional conflicts, including mobilizing
hospital ships, supporting Navy fleet and Marine Corps operations
ashore and afloat and numerous fleet hospitals, and maintaining
military treatment facilities outside the United States; (2) a
day-to-day operational support mission for the Navy fleet and Marine
Corps that allows Navy personnel to rotate between the United States
and operational Navy platforms and overseas assignments and that
includes GME; and (3) a peacetime health benefit mission providing
health care benefits in military treatment facilities in the United
States. 

While the Navy views all three missions as imperative to Navy
medicine under the THCSRR model, the first two are to determine the
number of needed active duty personnel.  It is only because of the
first two missions of wartime readiness and day-to-day operational
support that active duty Navy personnel are to be available to
support the third mission of providing peacetime health care
benefits. 

Pressure to develop a model such as THCSRR came from a study by the
Office of the Secretary of Defense of the overall military health
services system and the system's wartime medical force requirements;
commonly referred to as the 733 study, it was required by section 733
of the 1992 National Defense Authorization Act and was completed in
1994.  The 733 study examined the total medical care requirements
needed to support all three services during a post-cold war wartime
scenario along with peacetime health care requirements.  The study
concluded that the three services' medical force requirements for the
two major regional conflict scenarios would be significantly reduced
from earlier global wartime scenarios.  However, the Navy saw a need
for further study on its own to adequately determine its medical
force requirements for day-to-day operational support and to combine
those requirements with the wartime requirements to define the
minimum number of fully trained active duty personnel required to
accomplish both missions.  The determinations for operational support
requirements include the needed flow of trained physicians from GME. 


   OTHER SIZING MODELS AND
   STANDARDIZATION
-------------------------------------------------------- Appendix II:2

The Army and Air Force have independently developed sizing models to
project their readiness needs, including GME requirements, and Health
Affairs has presented a DOD medical sizing model to all three
services to promote the standardization of requirements
determinations and has used that model to compare requirements
projections by the three services.  A comparison in March 1997 showed
that the Army's model included consideration of GME requirements
beyond readiness to include what the Army defined as "peacetime
mission," thus projecting more needed training positions than did the
DOD model.  Health Affairs used the Navy's THCSRR model as the
starting point for the DOD model, specifying the same three critical
DOD health care missions of readiness, day-to-day operational
support, and peacetime health care and providing that only the first
two missions are to determine the required number of active duty
personnel.  Also, use of the DOD medical sizing model is to be
reflected in an ongoing update to the 733 study, which was initially
to be completed by the end of March 1996 and may lead to a more
standardized sizing approach. 




(See figure in printed edition.)Appendix III
COMMENTS FROM THE DEPARTMENT OF
DEFENSE
========================================================== Appendix II



(See figure in printed edition.)


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