Wartime Medical Care: Personnel Requirements Still Not Resolved (Letter
Report, 06/28/96, GAO/NSIAD-96-173).

Pursuant to a legislative requirement, GAO assessed the military's
wartime medical care requirements, focusing on the models used to
determine wartime medical personnel requirements.

GAO found that: (1) each service uses its own model to determine wartime
medical personnel requirements; (2) the services' wartime medical
personnel estimates are nearly the same as those projected for fiscal
year 1999; (3) the services' have maintained the same number of active
duty physicians even though active duty end strengths dropped
considerably; (4) the services' modeling techniques are reasonable and
consider factors such as defense planning, DOD evacuation plans,
casualty projections, and active duty and reserve medical personnel
requirements; (5) DOD is developing a new estimate of wartime medical
demands and associated personnel requirements based on updated
deployment projections; (6) DOD is experiencing difficulty in
formulating a single model that determines the population-at-risk and
casualty rate; and (7) due to this difficulty, DOD is using a unified
DOD sizing model to support individual service models.

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

 REPORTNUM:  NSIAD-96-173
     TITLE:  Wartime Medical Care: Personnel Requirements Still Not 
             Resolved
      DATE:  06/28/96
   SUBJECT:  Physicians
             Warfare
             Defense contingency planning
             Health care personnel
             Reductions in force
             Emergency preparedness
             Health services administration
             Health resources utilization
             Personnel management
IDENTIFIER:  Total Army Medical Department Personnel Structure Model
             DOD Military Health Services System
             
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Cover
================================================================ COVER


Report to Congressional Committees

June 1996

WARTIME MEDICAL CARE - PERSONNEL
REQUIREMENTS
STILL NOT RESOLVED

GAO/NSIAD-96-173

Wartime Medical Personnel

(703105)


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

  DOD - Department of Defense
  CINC - Commander in Chief
  MHSS - Military Health Services System
  MRC - Major Regional Conflict
  TAA - Total Army Analysis
  TAPSM - Total Army Medical Department Personnel Structure Model

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


B-272146

June 28, 1996

Congressional Committees

Since 1994, the Department of Defense (DOD) and the services have
produced several estimates of wartime medical personnel requirements. 
Section 745 of the 1996 National Defense Authorization Act (P.  L. 
104-106, February 10, 1996) directed us to study the reasonableness
of the models each military service uses to determine appropriate
wartime medical personnel force levels and to report our study
results not later than June 30, 1996.  Section 745 specifically
required us to include (1) an assessment of the modeling techniques
each service uses; (2) an identification of the models' ability to
integrate reserve personnel to meet department requirements; (3) an
analysis of the data used; and (4) an evaluation of the Secretary of
Defense's ability to integrate the various modeling efforts into a
comprehensive, coordinated plan for obtaining the optimum force level
for wartime medical personnel. 

After the section 745 language was drafted, DOD embarked on, but has
not completed, another major wartime medical requirements study. 
This study is expected to modify the data contained in the service
models and is intended to produce a unified DOD position on medical
requirements.  Because the study's results were unavailable as a
baseline comparison, we were unable to fully respond to all section
745 objectives.  This report reflects the status of our work to date. 
Specifically, it addresses the service models' results, their
methodologies, and their inclusion of active duty and reserve medical
personnel.  In a separate report, we will examine DOD's updated
wartime medical requirements study and, to the extent needed, address
any remaining issues associated with the service models. 


   BACKGROUND
------------------------------------------------------------ Letter :1

The Military Health Services System (MHSS), with an annual cost of
over $15 billion, has the dual mission of providing medical care to
the military forces during war or conflict and to military dependents
and retirees.  The MHSS consists of over 90 deployable combat
hospitals that are solely devoted to the wartime mission.  In
addition, over 600 medical treatment facilities, such as medical
centers, community hospitals, and clinics, are available worldwide to
care for wartime casualties, but also provide peacetime care to
active duty dependents and retirees.  The system employs over 184,000
military personnel and civilians with an additional 91,000 medical
personnel in the National Guard and Selected Reserves. 

In the post-Cold War era, personnel downsizing and constrained
budgets focused attention on DOD's need to determine the appropriate
size and mix of its medical force.  In 1991, the Congress required
DOD to reassess its medical personnel requirements based on a
post-Cold War scenario.  Specifically, section 733 of the National
Defense Authorization Act for Fiscal Years 1992 and 1993 (P.  L. 
102-190, December 5, 1991) required, among other things, that DOD
determine the size and composition of the military medical system
needed to support U.S.  forces during a war or other conflict and
identify ways of improving the cost-effectiveness of medical care
delivered during peacetime. 

In April 1994, DOD completed the required study, known as the "733
study." Although the study included all types of medical personnel,
it used physicians to illustrate key points.  It estimated that about
50 percent of the 12,600 active duty physicians projected for fiscal
year 1999 were needed to treat casualties emanating from two nearly
simultaneous major regional conflicts (MRC).  When reserve forces
were included, the study showed that the 19,100 physicians projected
for fiscal year 1999 could be reduced by 24 percent.  In March 1995,
we testified that the 733 study results were credible and that its
methodology was reasonable.\1 However, we noted that the study's
results differed from the war plans prepared by the commanders in
chief (CINC) for the two anticipated conflicts, due mainly to
different warfighting and casualty assumptions. 


--------------------
\1 Wartime Medical Care:  Aligning Sound Requirements With New Combat
Care Approaches Is Key to Restructuring Force (GAO/T-NSIAD-95-129,
Mar.  30, 1995). 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :2

In 1995, each service used its own model to determine wartime medical
personnel requirements instead of adopting the 733 study's results. 
Taken together, the services' models offset nearly all of the
reductions estimated in the 733 study, supporting instead, a need for
about 96 percent of the active duty physicians projected for fiscal
year 1999.  Much of this difference resulted because the services
assumed that significantly more people were needed for training and
maintaining personnel to relieve deployed medical forces.  Given
these results, DOD has not planned significant reductions in future
medical forces.  By comparison, the overall DOD active duty end
strengths are expected to decline by twice the rate of decline in
medical forces from fiscal year 1987 to fiscal year 1999. 

The modeling techniques the services used to determine medical
requirements appear reasonable.  However, the results of the models
depend largely on the values of the input data and assumptions used. 
Although their techniques differed in some ways, the services
appropriately considered factors, such as current defense planning
guidance, DOD policies for evacuating patients from the theater, and
casualty projections.  The service models also included requirements
for both active duty and reserve medical personnel.  At the time of
our review, the services had done more detailed analyses of the
active duty requirements than the reserve portion. 

Given the dichotomy between the results of the service models and the
733 study, in August 1995, the Deputy Secretary of Defense directed
that the 733 study be updated and improved.  This ongoing study is
intended to form the basis for a single DOD position on wartime
medical demands and associated personnel.  As such, it is to resolve
differences in the key assumptions that drive medical force
requirements.  While the study was to be completed by March 1996, DOD
has encountered difficulty in reaching agreement over some
assumptions, such as the population-at-risk and casualty rates. 
Thus, the study has been delayed.  The 733 update is using a unified
DOD sizing model, which will supplant individual service models. 


   SERVICE MODELS ESTIMATE MEDICAL
   PERSONNEL REQUIREMENTS MUCH
   HIGHER THAN THE 733 STUDY
------------------------------------------------------------ Letter :3

Following the 733 study, each service used its own model to determine
wartime medical personnel requirements.  Using these models, the
services estimated that their wartime medical personnel requirements
were almost as much as those projected for fiscal year
1999--offsetting most of the reductions suggested in the 733 study. 
Over the past several years, the services have maintained essentially
the same number of active duty physicians, even though active duty
end strengths have dropped considerably. 

The Navy developed a model known as the Total Health Care Support
Readiness Requirement to correct what it viewed as inaccuracies in
the 733 study.  The Air Force also developed a model patterned
closely after the Navy's.  In their models, the Navy and the Air
Force used the medical personnel levels from the 733 study as their
wartime baseline and then identified adjustments which, in their
view, were needed to more accurately represent personnel required to
treat combat casualties and to maintain operational readiness and
training.  Using these models, the Navy and the Air Force, in the
summer of 1995, identified wartime active duty medical personnel
requirements that supported 99 percent and 86 percent, respectively,
of their fiscal year 1999 projections. 

The Army also developed a model called Total Army Medical Department
Personnel Structure Model (TAPSM) to determine medical personnel
required to meet the medical demands of the two-MRC strategy.  TAPSM
differed from the Navy's and the Air Force's models in that the Army
continued using its Total Army Analysis (TAA) process to estimate the
baseline wartime requirements, whereas the Navy and the Air Force
used the 733 estimates as their baseline.  Building on the baseline
obtained from TAA, the Army used TAPSM to determine additional
medical personnel needed for medical readiness, such as rotation and
training.  In the summer of 1995, the Army's process identified
wartime active duty medical personnel requirements that were 104
percent of the Army's fiscal year 1999 projections. 

Major differences between the results of the service models and the
733 study occurred because the services made different assumptions
about the personnel needed for medical readiness.  These readiness
requirements are intended to ensure that, at any point in time, DOD
has enough personnel to care for deployed forces.  Specifically,
these readiness-related requirements support continuous training of
medical personnel and a medical cadre in the United States that can
replace or relieve deployed personnel as needed.  While the 733 study
made some provision for such requirements, the services' estimates
assume that a much higher number of medical personnel are needed for
such training and rotation. 

The services' estimates of wartime requirements support a medical
force projection that does not decrease nearly as much as the active
duty force.  Responding to changes in the national military strategy,
DOD projects that by 1999 the active duty force will be reduced by
one-third from the 1987 levels.  At the same time, the services are
projecting reductions of 16 percent in total active duty medical
personnel and 4 percent in active duty physicians. 


   SERVICES' MODELING TECHNIQUES
   APPEAR REASONABLE
------------------------------------------------------------ Letter :4

The services' modeling techniques for estimating medical personnel
requirements appear reasonable.  While we found some differences
between the models, each determined requirements for similar
categories of personnel.  However, the models' results depend largely
on the values of the input data and assumptions. 

We assessed the services' modeling techniques by comparing the
attributes of each model to the methodology used in the 733 study,
which we had previously concluded was reasonable.  We found that the
services' modeling techniques were consistent with the 733 study in
that they used (1) current defense planning guidance for two MRCs,
(2) DOD-approved policies for evacuating casualties from the theater,
and (3) casualty projections.\2

Also like the 733 study, the services' techniques included active
duty and reserve personnel working in hospital and nonhospital
functions, those working in graduate medical education programs, and
those needed for rotation to overseas installations.  However, as
described previously, the services assumed more medical personnel
would be needed for training and rotation associated with medical
readiness.  These assumptions, not the modeling techniques, accounted
for a major difference between the results of the 733 study and the
services' models.  The 733 study concluded that about 50 percent of
the active duty physicians projected for fiscal year 1999 were not
needed to meet wartime medical readiness requirements, while the
services' models supported a need for 96 percent of the fiscal year
1999 active duty physicians. 

DOD's current study of wartime medical personnel requirements, when
completed, will present another analysis to compare with the
services' modeling techniques.  This analysis could reveal
methodological or other differences not currently identified. 


--------------------
\2 Casualty projections are based on several assumptions about
fighting a war, such as the population-at-risk, the severity of a
conflict, the duration of combat, and injury rates.  The actual
number of casualties resulting from any model will vary according to
values assigned to these assumptions.  If large numbers of people are
in a combat theater, for example, casualties are likely to be higher
than would be the case with a smaller population-at-risk. 


   SERVICE MODELS INCLUDE
   REQUIREMENTS FOR ACTIVE AND
   RESERVE MEDICAL PERSONNEL
------------------------------------------------------------ Letter :5

In the services' medical personnel requirements processes, the demand
for care emanating from the two-MRC strategy is translated into the
number of hospital beds required.  This demand is based on the number
of anticipated casualties without regard to whether the beds will be
staffed by active duty or reserve component medical personnel.  The
allocation between active and reserve components is made by analyzing
when casualties are projected to occur during the conflicts and
comparing that requirement to information on how soon active and
reserve medical units can arrive in the theater.  If high numbers of
casualties in a theater are anticipated to occur early in a conflict,
more active duty medical personnel will likely be required to provide
medical care because active duty medical units generally can deploy
more quickly than reserve units.  Conversely, if high numbers of
casualties do not occur until later in the conflict, the need for
active duty medical personnel diminishes and more requirements can be
met by reserve forces. 

DOD's current study of medical requirements will examine the
appropriateness of the mix between active duty and reserve medical
forces.  The outcome of this study will have important ramifications
for sizing the medical components of each service and the number of
medical personnel to remain on active duty status.  If, for example,
the study assumes that medical forces will be needed sooner than
assumed in the 733 study, most, if not all, of the reductions in
active duty medical personnel estimated in the original study could
be nullified.  On the other hand, if medical forces are assumed to
deploy later, more reductions in active duty medical personnel could
be made. 


   733 UPDATE IS USING A PROCESS
   INTENDED TO SUPPLANT INDIVIDUAL
   SERVICE MODELS
------------------------------------------------------------ Letter :6

DOD is currently updating its 733 study using a process intended to
replace the individual service models for determining wartime medical
personnel requirements.  The update was directed by the Deputy
Secretary of Defense, in August 1995, to respond to the continuing
debate over the estimates for wartime medical personnel.  The update
is being led by the Director of DOD's Office of Program Analysis and
Evaluation, which also conducted the original 733 study, under the
general direction of a steering group of representatives from several
offices. 

The update will result in a new estimate of wartime medical demands
derived from updated planning scenarios and force deployment
projections.  In an effort to arrive at one set of DOD requirements,
the 733 update working groups have been attempting to reach agreement
on the underlying assumptions with the key parties within DOD. 
However, the March 1996 completion has been delayed because of
disagreements over some assumptions, such as the population-at-risk
and casualty rates.  DOD officials have not provided a firm date for
completing the study, but they believe they are making progress in
reaching agreement on input assumptions.  They also believe such an
agreement will establish a unified process for determining DOD-wide
wartime medical demands. 

After the wartime demand is established, the 733 update is expected
to use a model to estimate medical personnel needed to meet the
demand.  DOD officials believe that, in the future, this model--the
DOD Medical Sizing Model--will be used to determine total wartime
medical personnel levels.  According to DOD officials, if agreement
is reached on the model and the assumptions to be used, wartime
medical requirements will no longer be determined by the individual
service models. 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :7

We reviewed documents, reports, and legislation relevant to military
medical staffing trends; each service's medical staffing model; the
DOD Medical Sizing Model; and the 733 update study.  We interviewed
officials from the Office of the Assistant Secretary of Defense for
Health Affairs; DOD's Office of Program Analysis and Evaluation; the
Joint Staff; the Offices of the Surgeons General of the Army, the
Navy, and the Air Force; the Office of Reserve Affairs; and the U.S. 
Army Concepts Analysis Agency in the Washington, D.C., area.  We also
interviewed officials from the U.S.  Central Command, Tampa, Florida;
the U.S.  Transportation Command, Scott Air Force Base, Illinois; and
the Army Medical Command, San Antonio, Texas. 

In assessing the reasonableness of the services' modeling techniques,
we compared the attributes of each model with the 733 study.  We
obtained information from each service on the model formats, the
underlying assumptions, and the types and sources of information used
in developing the models.  We met with the service representatives
responsible for developing and using the models to gain an
understanding of how each model worked.  We did not attempt an
in-depth validation of the accuracy of each model, rather, we
reviewed the models to see if their methodologies were generally
consistent with the 733 study. 

We initially concentrated on looking at how each model developed the
active duty medical personnel requirements from the total wartime bed
requirements.  We also compared the services' modeling techniques
with each other.  We intended to compare each service's input values
(rates) for such factors as wounded-in-action, conflict intensities,
conflict durations, and disease and non-battle injuries with similar
rates depicted in the CINC war plans and with the updated casualty
rates being developed subsequent to the 733 study.  However, before
we started this phase, DOD decided to develop, as part of the 733
update, a single DOD-wide model for determining medical staffing
requirements.  Since the update is still ongoing, we are at this time
unable to fully assess the reasonableness of the data inputs and
assumptions, the appropriateness of the active/reserve component
split, and the degree to which DOD integrates the medical
requirements of the three services. 

We conducted our review from June 1995 to June 1996 in accordance
with generally accepted government auditing standards. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

In oral comments, DOD fully concurred with this report's findings and
conclusions. 


---------------------------------------------------------- Letter :8.1

We are sending copies of this report to other interested
congressional committees; the Secretaries of Defense, the Army, the
Navy, and the Air Force; the Commandant, U.S.  Marine Corps; and the
Director, Office of Management and Budget.  We will also send copies
to others on request. 

If you or your staff have any questions about this report, please
call me on (202) 512-5140.  Major contributors to this report are
listed in appendix I. 

Mark E.  Gebicke
Director, Military Operations
  and Capabilities Issues

List of Congressional Committees

The Honorable Strom Thurmond
Chairman
The Honorable Sam Nunn
Ranking Minority Member
Committee on Armed Services
United States Senate

The Honorable Dan Coats
Chairman
The Honorable Robert C.  Byrd
Ranking Minority Member
Subcommittee on Personnel
Committee on Armed Services
United States Senate

The Honorable Floyd Spence
Chairman
The Honorable Ronald Dellums
Ranking Minority Member
Committee on National Security
House of Representatives

The Honorable Robert K.  Dornan
Chairman
The Honorable Owen B.  Pickett
Ranking Minority Member
Subcommittee on Military Personnel
Committee on National Security
House of Representatives


MAJOR CONTRIBUTORS TO THIS REPORT
=========================================================== Appendix I


   NATIONAL SECURITY AND
   INTERNATIONAL AFFAIRS DIVISION,
   WASHINGTON, D.C. 
--------------------------------------------------------- Appendix I:1

Sharon A.  Cekala
Paul L.  Francis
Valeria G.  Gist
Dade B.  Grimes
Christina Quattrociocchi


   NORFOLK REGIONAL OFFICE
--------------------------------------------------------- Appendix I:2

Steve J.  Fox
Lynn C.  Johnson
William L.  Mathers
Dawn R.  Godfrey


   DALLAS REGIONAL OFFICE
--------------------------------------------------------- Appendix I:3

Jeffrey A.  Kans
Cary B.  Russell


*** End of document. ***