Wartime Medical Care: DOD Is Addressing Capability Shortfalls, but
Challenges Remain (Letter Report, 09/25/96, GAO/NSIAD-96-224).

Pursuant to a congressional request, GAO reviewed the Department of
Defense's (DOD) efforts to reassess and improve its medical
capabilities, focusing on: (1) DOD implementation of its Medical
Readiness Strategic Plan (MRSP); (2) the services' medical reengineering
efforts; and (3) the Military Health Services System (MHSS) 2020 project
to identify future wartime medical system requirements.

GAO found that: (1) DOD and the services are making progress to correct
the medical capability problems that have hampered recent military
operations; (2) MRSP appropriately focuses on problems that GAO and DOD
have identified; (3) DOD is placing increased emphasis on implementing
MRSP, after a slow start; (4) many key MRSP tasks are unfunded or
partially funded; (5) the services are reconfiguring their combat
hospitals into smaller components and undertaking efforts to
significantly enhance their current medical system capabilities; (6) the
MHSS 2020 Project has not yet identified how military health
capabilities should be funded and staffed in the future; and (7) until
MHSS 2020 is completed, DOD cannot determine how compatible MRSP and
service reengineering programs will be with future requirements.

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

 REPORTNUM:  NSIAD-96-224
     TITLE:  Wartime Medical Care: DOD Is Addressing Capability 
             Shortfalls, but Challenges Remain
      DATE:  09/25/96
   SUBJECT:  Combat readiness
             Defense contingency planning
             Health care personnel
             Health resources utilization
             Military hospitals
             Mobilization
             Management information systems
             Logistics
             Armed forces reserves
             Medical supplies
IDENTIFIER:  DOD Medical Readiness Strategic Plan
             Desert Storm
             DOD Military Health Services System
             DOD Military Health Services System 2020 Project
             Naval Expeditionary Medical Support System
             
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Cover
================================================================ COVER


Report to the Chairman, Subcommittee on Military Personnel, Committee
on National Security, House of Representatives

September 1996

WARTIME MEDICAL CARE - DOD IS
ADDRESSING CAPABILITY SHORTFALLS,
BUT CHALLENGES REMAIN

GAO/NSIAD-96-224

Wartime Medical Care

(703104)


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

  DOD - Department of Defense
  MHSS - Military Health Services System
  MRSP - Medical Readiness Strategic Plan

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


B-274015

September 25, 1996

The Honorable Robert K.  Dornan
Chairman, Subcommittee on Military Personnel
Committee on National Security
House of Representatives

Dear Mr.  Chairman: 

As you requested, we determined whether the Department of Defense's
(DOD) and the services' efforts to reassess and improve their medical
capabilities have been properly focused and coordinated to result in
the most effective wartime medical system.  Specifically, we reviewed
DOD's development, management, and implementation of its Medical
Readiness Strategic Plan (MRSP) and the services' medical
reengineering efforts.  We also examined DOD's ongoing project to
identify future wartime medical system requirements. 


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

Operation Desert Storm revealed many weaknesses in medical
capabilities of U.S.  forces.  Subsequent studies conducted by us and
the DOD Inspector General revealed shortcomings in DOD's ability to
provide adequate, timely medical support during contingencies and
problems with the planning and execution of these efforts.  The Joint
Staff also identified problems with the current design of DOD's
wartime medical system.  In response to these problems, DOD and the
services embarked on initiatives to correct shortfalls in wartime
medical capabilities and improve medical readiness.  The decisions
that emanate from these efforts over the next few years will
determine how wartime medical care will be provided for the
foreseeable future. 

In March 1995, DOD published MRSP to serve as a road map for
attaining and sustaining military medical readiness into the 21st
century.  The Office of the Assistant Secretary of Defense for Health
Affairs is responsible for managing MRSP.  In developing its MRSP,
Health Affairs convened panels of both military and civilian experts
to assess medical capability shortfalls in nine functional areas: 
planning; requirements, capabilities, and assessment; command,
control, communications, computers, and information management;
logistics; medical evacuation; personnel; training; blood supply; and
readiness oversight.  For each functional area, the expert panels
developed strategic objectives to support the continuum of military
operations envisioned in the defense planning guidance for fiscal
years 1996-2001.  A total of 42 action plans were developed to
address shortfalls in the 9 functional areas.  In assessing these
shortfalls, the panels relied heavily on the reports that we and the
DOD Inspector General prepared on the medical reponse during
Operation Desert Storm.  The panels also identified the offices to be
responsible for developing and executing detailed implementation
plans. 

DOD is engaged in other efforts related to the wartime medical care
system.  Each service initiated a reengineering program to reassess
and reconfigure its wartime medical capabilities to be more
compatible with plans for two major regional conflicts and operations
other than war.  DOD is also trying to forecast the wartime medical
demands in the year 2020 and design a military health services system
that will be responsive to those demands (known as the MHSS 2020
project).  In a separate effort, DOD is also updating an April 1994
study (known as the 733 update) to determine wartime medical
personnel requirements for the year 2001. 


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

DOD and the services are making progress in addressing the medical
capability shortfalls that hampered their operations during Operation
Desert Storm and other smaller scale operations.  MRSP appears to
appropriately focus on the medical problems that we, the Joint Staff,
and the DOD Inspector General have observed.  Although Health Affairs
got off to a slow start in managing the implementation process for
MRSP, the office has been placing increased emphasis in this area. 
About 44 percent of the corrective action tasks have been reported as
completed.  However, Health Affairs does not know whether these
actions have corrected the problems.  Some corrective action plans
have not been submitted, and about 7 percent of corrective action
tasks have been reported as behind schedule.  Funding may also be an
obstacle to implementation, since many key tasks requiring funding
are either unfunded or partially funded. 

The services' medical reengineering programs are addressing common
goals:  to be lighter, smaller, more mobile, and adaptable to
different mission requirements.  The changes arising from these
reengineering programs appear to provide significant enhancements to
current medical system capabilities.  To respond to the mobility
problems encountered in Operation Desert Storm, for example, the
services are reconfiguring their combat hospitals into smaller
components. 

Even though DOD's MRSP and the services' reengineering programs are
focused on correcting current and near-term medical problems, DOD's
MHSS 2020 project has yet to reveal how the future wartime medical
system should look.  Consequently, it is unknown how compatible the
current efforts to improve wartime medical care will be with the
future military health services system. 


   DOD NEEDED TO IMPROVE ITS
   WARTIME MEDICAL CAPABILITIES
------------------------------------------------------------ Letter :3

To respond to the new national military strategy resulting from the
end of the Cold War and problems that we, the Joint Staff, and the
DOD Inspector General identified, DOD initiated efforts to improve
its wartime medical capabilities.  Defense planning guidance,
modified in May 1994, requires DOD to be ready to engage in two
nearly simultaneous major regional conflicts and prepare for smaller
scale operations other than war.  DOD assumed that future operations
would have far shorter warning times and durations than Cold War
scenarios. 

The transition to the current defense planning guidance, particularly
the projected shorter warning times, increased DOD's emphasis on
joint service operations and the need to react quickly to a major
regional conflict or an operation other than war.  This transition
has also underscored the need for the services to redesign their
wartime medical systems to reduce transportation demands because of
limited lift capacity.  Medical systems must compete with the
movement of combat troops and other war-fighting materials to the
theater. 

On the basis of war games conducted in December 1994, the Joint Staff
determined that the commanders in chief were unable to provide
adequate lift capability to move medical logistics and deployable
hospitals to support two nearly simultaneous major regional
conflicts.  The Joint Staff recommended that the services investigate
the possibility of evacuating casualties more quickly to the United
States for treatment.  The Joint Staff believed anticipated conflicts
might be of such short duration that it would be unlikely that the
soldiers would be well enough to return to duty after treatment in
the theater.  On the basis of war games completed in March 1995, the
Joint Staff also recommended that the services approach medical
operations from a joint perspective and redesign their medical
systems assuming smaller and lighter deployable hospitals and quicker
evacuation of patients to the United States for treatment. 

On September 30, 1993, the DOD Inspector General issued a report
outlining several wartime medical problems that were consistent with
Joint Staff observations.\1 The Inspector General criticized DOD for
a lack of joint medical planning.  The report stated that DOD could
not ensure the deployability of medical personnel during
contingencies for several reasons, including outdated methods for
determining personnel requirements, assignment of personnel to
incorrect skill areas, and inadequate training of medical personnel. 
The report also stated that DOD's deployable hospitals lacked
sufficient mobility and had incompatible communication capability
that limited their ability to prepare for incoming casualties. 

We have issued a series of reports that describe problems in DOD's
wartime medical planning and capability to provide wartime medical
care.\2 We found that understaffed and inadequately supplied and
equipped medical units in Operation Desert Storm might not have been
able to provide adequate care if the predicted number of casualties
had occurred.  Also, the medical units were not staffed and equipped
to provide noncombat care and were unable to support the evacuation
of casualties from the combat theater or receive large numbers of
chemically contaminated casualties.  Other medical force problems
included (1) large numbers of nondeployable medical personnel due to
unacceptable physical conditions, lack of required skills, and
mismatches in medical specialties; (2) a widespread lack of training
for the wartime missions; and (3) inadequate or missing equipment and
supplies. 

In addition, we testified in March 1995 that several key factors,
such as the population at risk and wounded-in-action rates, that
affect the demand for wartime medical care were still being
debated.\3 We also stated that reaching agreement on the key factors
was critical to arriving at the best wartime medical care system for
the future, as it would allow decisionmakers to direct their
attention to optimizing the medical care system for that demand.  We
reported in June 1996 that DOD was still having difficulty reaching
agreement on such factors.\4


--------------------
\1 Medical Mobilization Planning and Execution, DOD Inspector General
(93-INS-13, Sept.  30, 1993). 

\2 Operation Desert Storm:  Problems with Air Force Medical Readiness
(GAO/NSIAD-94-58, Dec.  30, 1993); Operation Desert Storm: 
Improvements Required in the Navy's Wartime Medical Program
(GAO/NSIAD-93-189, July 28, 1993); Operation Desert Storm:  Full Army
Medical Capability Not Achieved (GAO/NSIAD-92-175, Aug.  18, 1992). 

\3 Wartime Medical Care:  Aligning Sound Requirements With New Combat
Care Approaches Is Key to Restructuring Force (GAO/T-NSIAD-95-129,
Mar.  30, 1995). 

\4 Wartime Medical Care:  Personnel Requirements Still Not Resolved
(GAO-NSIAD-96-173, June 28, 1996). 


   MRSP APPROPRIATELY DESCRIBES
   READINESS PROBLEMS, BUT
   CHALLENGES REMAIN
------------------------------------------------------------ Letter :4

Our comparison of problems highlighted by MRSP with those we, the
Joint Staff, and the DOD Inspector General had previously identified
shows that MRSP appropriately describes medical readiness problems
needing resolution.  The problems outlined in MRSP are also
consistent with the recent changes in the Defense Planning Guidance. 
For example, MRSP points out that current medical planning is based
on Cold War assumptions in which the services planned to fight the
former Soviet Union individually rather than jointly.  This lack of a
joint approach made the DOD medical system unresponsive to the full
continuum of anticipated contingencies, including major regional
conflicts, peacemaking, and disaster relief.  Accordingly, MRSP lists
specific tasks Health Affairs, the services, the Joint Staff, and
other DOD activities should take to ensure that joint medical
planning becomes standard throughout DOD. 

MRSP also identifies the need for the services to modernize their
deployable hospitals to reduce their weight and size.  This reduction
will decrease transportation demands and improve the mobility and
transportability of such hospitals.  It lists steps, such as
incorporating technological advancements and equipment modernization,
to correct these problems.  Similarly, MRSP describes many factors
that inhibit the deployability of medical personnel and lists steps
to improve the training and certification of medical personnel to
ensure they are adequately prepared to perform functions expected of
them while deployed. 

MRSP outlines corrective actions to address problems in the
communications area such as ensuring interoperability and
adaptability of individual service medical communication with global
communications systems.  It also requires specific DOD offices to
ensure the availability of critical medical materials needed for a
conflict.  MRSP also stresses the need for DOD and the services to
reexamine and validate the key factors that affect the demand for
wartime medical care. 

Three additional areas are currently being added to MRSP:  nuclear,
biological, and chemical warfare; operations other than war; and
research and development.  For each area, an expert panel identified
capability shortfalls and developed corrective actions.  Health
Affairs plans to add these new areas to MRSP by December 31, 1996. 


      MRSP STARTED SLOWLY
---------------------------------------------------------- Letter :4.1

Health Affairs got off to a slow start in monitoring progress being
made in correcting medical readiness problems.  The primary tool
Health Affairs uses to monitor progress is its review of periodic
updates of implementation plans submitted by the responsible offices. 
These plans summarize how and when a responsible office intends to
correct a particular medical readiness problem described in MRSP. 
Although the implementation plans do not indicate the amount of
funding involved, they describe whether specific corrective actions
are fully or partially funded or unfunded.  MRSP requires 400
implementation plans because of the multiple tasks and multiple
offices responsible for carrying out needed actions. 

Initially, Health Affairs had difficulty obtaining complete
implementation plans in a consistent format from the responsible
offices.  Although the offices were to submit the plans by the end of
June 1995, Health Affairs had not obtained 19 (5 percent) of the
required implementation plans as of April 30, 1996.  The Joint Staff
was responsible for six (32 percent) of the missing plans.  A Joint
Staff official said that staff turnover and competing priorities
delayed the submission of the implementation plans but that they
would be completed by the fall of 1996.  The other offices
responsible for the missing plans were Health Affairs, the Defense
Modeling and Simulation Office, and the Office of the Assistant
Secretary of Defense for Reserve Affairs.  In commenting on our draft
report, Health Affairs reported that it had obtained an additional 10
implementation plans, including all of the missing plans from the
Joint Staff. 

Health Affairs also had difficulty collecting and analyzing the
initial submissions because of the volume of information.  Health
Affairs corrected this situation by developing computer software to
facilitate the quarterly updating and analysis of the implementation
plans and sharing it with the responsible offices.  In addition,
Health Affairs entered into a contract with an outside firm to put
the implementation plans on a computerized network so the responsible
offices could continually keep them updated.  This project is
expected to be accomplished in December 1996. 

As a part of its monitoring efforts, in February 1996, Health Affairs
convened most of the experts that helped develop MRSP to determine
whether (1) the individual offices given responsibility for
correcting medical readiness problems in MRSP were still appropriate
and (2) the anticipated corrective actions described by those offices
were responsive to the current readiness problems.  These panels
recommended several changes in both responsibilities and needed
corrective actions.  If approved, the changes are expected to be made
to MRSP in October 1996. 


      CORRECTIVE ACTIONS ARE
      UNDERWAY, BUT MANY ARE
      BEHIND SCHEDULE
---------------------------------------------------------- Letter :4.2

Our analysis of the 1,362 specific tasks included in 400 MRSP
implementation plans shows that the responsible offices are making
progress in correcting medical readiness problems but that some tasks
are behind schedule.  More specifically, 604 (44.3 percent) of the
1,362 tasks were reported as completed, but 94 (6.9 percent) were
reported as behind schedule as of April 30, 1996.\5 Milestones for
completing the remaining 664 tasks have not yet occurred. 

During the summer of 1995, the Assistant Secretary of Defense for
Health Affairs and the Surgeons General of the services identified
the following six plans for priority monitoring:  joint medical
planning, information management, joint medical logistics and
planning, medical evacuation, deployability of medical personnel, and
medical readiness oversight.  The tasks for the six priority plans
and their implementation status are shown in table 1. 



                                Table 1
                
                   MRSP Tasks That Were Completed and
                Behind Schedule for Six Priority Action
                      Plans (as of Apr. 30, 1996)


                                     Total  Numbe  Perce  Numbe  Perce
Action plan                          tasks      r     nt      r     nt
----------------------------------  ------  -----  -----  -----  -----
Joint medical planning                  29     12     41      2      7
Information management                  17      7     41      0      0
Joint medical logistics and             52     27     52      4      8
 planning
Medical evacuation                      29      6     21      1      3
Deployability of medical personnel       6      1     17      0      0
Medical readiness oversight              3      3    100      0      0
======================================================================
Total                                  136     56     41      7      5
----------------------------------------------------------------------
Our analysis is meant to provide a general overview of how the
responsible DOD activities view their attempts to correct the medical
readiness problems assigned to them without regard to whether one
task is more critical than another.  Also, the corrective actions may
not be directly attributable to the MRSP process; some of the DOD
offices responsible for such issues had already undertaken corrective
actions.  (MRSP does not duplicate these efforts but attempts to
consolidate their oversight.)


--------------------
\5 This date was the last time the implementation plans were updated
by the responsible offices. 


      SEVERAL OBSTACLES MAY
      INHIBIT PROGRESS
---------------------------------------------------------- Letter :4.3

Although progress is being made in implementing MRSP, some potential
obstacles may hamper the timely correction of problems noted in the
plan.  One of these obstacles involves the three offices (Health
Affairs, the Defense Modeling and Simulation Office, and the Office
of the Assistant Secretary of Defense for Reserve Affairs) that have
not yet submitted detailed implementation plans for corrective
actions, which raises questions about whether problems are being
addressed.  Some DOD officials told us that they were concerned that
those offices outside the control of Health Affairs have not given
implementation of MRSP the level of attention it deserves.  In this
regard, the officials believe that MRSP would have been given higher
visibility and priority for implementation if it had been published
with the signature of the Secretary of Defense or Deputy Secretary of
Defense rather than the Assistant Secretary of Defense for Health
Affairs. 

Lack of funding may also hamper implementation of MRSP.  When MRSP
was published, no additional funding was given to responsible program
offices for implementing the plan.  Although the offices were
expected to fund the corrective actions from their ongoing
appropriations, many corrective actions were not funded or were only
partially funded as of April 30, 1996.  Health Affairs officials did
not know the amount of these funding shortfalls, but they were
planning to assess the impact of the shortfalls in 1997. 

Moreover, Health Affairs has limited knowledge regarding the extent
to which problems noted in MRSP have been resolved by the corrective
actions identified in the implementation plans.  Health Affairs is in
the process of developing a methodology for making this assessment
and plans to begin using it shortly after its completion in March
1997. 


   SERVICES' REENGINEERING
   PROGRAMS OFFER IMPROVEMENT
------------------------------------------------------------ Letter :5

Each service has initiated a medical reengineering program to address
shortfalls in medical capabilities.  Each reengineering program is at
a different stage of development but all are expected to yield
enhancements to current system capabilities by making organizational
changes, reconfiguring deployable systems, and adapting clinical
capabilities to different mission requirements.  The services
anticipate that these programs will meet their reengineering goals of
developing smaller and more mobile systems. 


      ARMY
---------------------------------------------------------- Letter :5.1

In early 1994, the Army's Surgeon General initiated a medical
reengineering program to reconfigure the Army's combat health support
operations.  This program was to incorporate the lessons learned from
Operation Desert Storm and other operations and reflect the types of
combat operations anticipated for the 21st century. 

In assessing how its combat health support system should be
reconfigured, the Army Medical Command assembled panels of experts
for 10 functional areas, such as hospitalization, medical evacuation,
and medical logistics.  The panels assessed current medical
capabilities and proposed organizational and operational changes. 
The proposed changes are designed to make medical systems modular and
more mobile and flexible.  Also, the changes are intended to make the
systems capable of effectively operating simultaneously in multiple
locations and tailored to accommodate missions ranging from intense
combat to peacekeeping and humanitarian operations. 

Significant changes are proposed for hospital care, which is
currently provided in three types of facilities:  the Combat Support
Hospital, Field Hospital, and General Hospital.  The Army is moving
toward smaller hospital modules that can provide a full range of
services and be self-sufficient and ready for rapid response.  One
reconfigured 248-bed hospital will replace the 3 current types of
hospitals.  This new hospital will consist of two self-supporting
modules:  a mobile 84-bed module and a larger 164-bed module.  The
84-bed module will provide increased flexibility because 3 of the
modules can be prepositioned aboard a ship and later deployed in
separate units if needed.  The current Combat Support Hospital must
be deployed as a single unit. 

The Mobile Army Surgical Hospitals are being phased out.  Their
mission of providing urgent resuscitative surgery will be assumed by
the mobile forward surgical teams, which will perform surgery at
locations deeper in the battlefield or closer to the place of
wounding.  To provide increased flexibility, a medical detachment
will be available to augment capability at hospitals throughout the
theater.  Specialty augmentation teams using the same equipment will
be consolidated, and another team will be added to provide
capabilities for operations other than war.  The proposal also
includes improved communications technology, information systems, and
use of telemedicine. 

In December 1995, the Army's Surgeon General approved the proposed
reengineering changes, and they are currently under review by the
Army's Training and Doctrine Command, the commanders in chief, and
major commands.  The changes are expected to be submitted to the
Army's Chief of Staff for approval in September 1996.  If approved,
implementation of the proposals will begin in fiscal year 2000 and be
completed by fiscal year 2005. 


      AIR FORCE
---------------------------------------------------------- Letter :5.2

The Air Force Surgeon General initiated a project in January 1994 to
reengineer approaches for delivering medical care during conflicts or
other kinds of operations.  The initiative consists of three phases: 
concept development, determination of feasibility, and
implementation. 

In June 1995, the Air Force Surgeon General approved a new concept
that envisions small deployable medical systems to allow commanders
more flexibility to tailor their medical care response to a specific
mission.  Currently, the Air Force generally deploys a 50-bed,
surgically intensive, air transportable hospital to a conflict. 
Under the new concept, more than 40 clinical modules, including
general surgery, primary care, intensive care, and dental services,
can be deployed individually or in various combinations.  According
to Air Force officials, the use of a more tailored approach requires
less airlift capacity and provides the types of services that are
appropriate for a specific mission. 

To provide additional mobility and flexibility, the standard air
transportable hospital can be scaled down to 25 beds, with an option
of deploying a 10-bed trauma clinic to stabilize trauma patients and
provide outpatient care.  The concept also uses telemedicine to give
forward deployed medical personnel the capability to obtain remote
consultations in several disciplines, including radiology,
dermatology, and pathology. 

To evacuate patients more quickly from the theater, the Air Force
plans to use critical care aeromedical transport teams to stabilize
and evacuate critically ill patients to the United States or other
locations for treatment.  Each team can be tailored to meet the needs
of specific patients, but the teams generally consist of a physician,
nurse, and respiratory therapist.  The Air Force is testing this
concept and has formed seven teams that have transported critically
ill patients from Bosnia and Saudi Arabia. 

During the summer of 1996, the Air Force realized that its proposed
reengineering changes were feasible.  As a result, officials have
initiated the implementation phase.  In addition, the officials were
trying to obtain funding through the 1998-2002 Program Objective
Memorandum cycle so that the changes could be fully implemented by
the end of fiscal year 2002. 


      NAVY
---------------------------------------------------------- Letter :5.3

The Navy's fleet hospital reconfiguration project began in the fall
of 1995 with the goal of making fleet hospitals lighter and more
mobile and mission flexible.  Two working groups are involved in the
study; one is focusing on reconfiguring fleet hospitals until the
year 2010, and the other is focusing on changes in 2010 and beyond. 

The first working group developed a preliminary design of a small
hospital, but the design has not been approved by Navy leaders.  The
proposed design, called the Naval Expeditionary Medical Support
System, focuses wartime medical capability around a core unit with a
capacity of 20 to 130 beds.  Although the current 500-bed fleet
hospital will be maintained, Navy officials envision that either the
130- or the 500-bed hospital will be set up in a given theater, but
not both.  In addition, the concept includes an option to extract a
100-bed unit from the standard 500-bed fleet hospital to use during
an operation other than war.  Under this concept, the Navy will not
maintain any duplicate equipment.  If the new concept is approved,
the fleet hospitals will be repackaged as they are brought in for
their periodic modernizing, beginning as early as 1998. 

The Navy is also revising its procedures for staffing hospitals.  The
Navy's requirement for fleet hospitals has decreased from 17 to 12. 
Six of these hospitals will be staffed primarily by active duty
personnel and six will be staffed by reserve personnel.  To increase
staffing efficiency and productivity, the Navy will now staff its
active duty deployable hospitals with personnel from specific medical
treatment facilities.  In the past, fleet hospitals were staffed by
pulling medical personnel from any location, but this approach did
not work particularly well in Operation Desert Storm.  The revised
concept presumes that medical personnel who work together on a
day-to-day basis will perform better than staff who are taken from
different locations within the system.  Similarly, the Navy plans to
designate specific reserve units to staff the six reserve component
fleet hospitals.  Other reserve medical units will be designated to
replace active duty staff taken from specific medical treatment
facilities. 

To ensure that active duty medical personnel earmarked for deployment
get the periodic readiness training they need, the Navy designated
the executive officers of medical treatment facilities as the
commanding officers of the fleet hospitals when they deploy.  For
reserve medical personnel in units designated to staff fleet
hospitals, Navy officials anticipate that the units will train
together at a fleet hospital every 2 years.  When the reservists do
not train at a fleet hospital, they will complete their annual 2-week
training session at a Navy medical treatment facility or at their
units' designated hospital. 


      MARINE CORPS
---------------------------------------------------------- Letter :5.4

In late 1993, the Marine Corps began to reassess the reconfiguration
of its medical battalions, which are part of its combat units.  The
need to reconfigure these battalions grew out of lessons learned from
Desert Storm showing that the battalions were too heavy to keep pace
with and support the movement of the ground combat units.  The Marine
Corps found that the capabilities of the medical battalions had been
expanded during the Vietnam War era to compensate for the lack of
deployable hospitals at higher echelons of care.  However, these
expanded capabilities were beyond the battalions' mission.  The
medical supplies and equipment included in each battalion, which
should have been assigned to a higher echelon of care, had greatly
increased the battalion's weight and size, and hampered its mobility. 

The restructuring of the medical battalion essentially reduced those
specialty care capabilities that were beyond the mission
requirements.  This restructuring also placed more reliance on
evacuating patients needing such specialty care to higher echelons of
care provided by the Navy or other services.  In addition, the
restructuring reduced the number of cots by 52 percent, from 540 to
260, and reduced the weight of the medical battalion by 20 percent. 
The new surgical companies within the battalion are staffed with
general surgeons and trauma care providers and no longer contain
orthopedic and other surgical subspecialties, such as thoracic
surgeons.  Patients requiring specialty care will be evacuated to
other facilities where such care is available.  Marine Corps
officials believe that the restructured medical battalion, with its
decreased lift requirement and smaller footprint, will allow the
battalion to move with the combat maneuver elements and provide
direct resuscitative health service support to the combat forces. 

The Commandant of the Marine Corps approved the restructured medical
battalion in November 1995.  Two of the four Marine Corps medical
battalions have begun implementing the restructuring, and the others
will begin reconfiguration by October 1996.  Full implementation of
the restructuring is expected by the year 2000, assuming funding is
available from the Program Objective Memorandum process. 


   COMPATIBILITY OF DOD'S FUTURE
   MILITARY MEDICAL SYSTEM WITH
   CURRENT EFFORTS IS UNKNOWN
------------------------------------------------------------ Letter :6

In February 1996, Health Affairs began its MHSS 2020 project to
forecast changes in health care delivery, with the goal of
facilitating the integration of these future health care practices
into the design of the military health services system.  The project
is designed to identify 25-year trends and breakthroughs in both
clinical and nonclinical technologies; determine how to apply these
technologies across DOD health care responsibilities, which range
from personal fitness to treatment of war zone casualties; and
identify how the military health services system should be funded and
staffed to transition to the year 2020. 

Participants in the project include practitioners, researchers, and
academicians from several disciplines in the federal and private
sectors.  The project will involve three stages.  First, about 200
experts--organized into 20 specialized working groups concentrating
on clinical, administrative, and information management issues--will
identify future trends in their fields.  Second, 10 multidisciplinary
groups will develop strategic planning scenarios for specific areas
of military health from the trend information.  Third, teams will
identify general and specific proposals to help transition the
current military health services system from today to the year 2020. 
DOD expects the future scenarios to be finalized in December 1996. 

The MHSS 2020 project could serve as the mechanism for identifying
future medical system requirements against which MRSP and the
services' reengineering programs should be focused.  However, the
extent to which MRSP and these reengineering programs will be
compatible with future medical system requirements will not be known
until the MHSS 2020 project is completed. 


   RECOMMENDATIONS
------------------------------------------------------------ Letter :7

We recommend that the Secretary of Defense direct Health Affairs, the
Defense Modeling and Simulation Office, and the Office of the
Assistant Secretary of Defense for Reserve Affairs to develop and
begin implementing plans to correct the medical capability problems
noted in MRSP.  Without such direction, these offices might continue
to give low priority to medical readiness. 

We also recommend that the Secretary of Defense direct the Assistant
Secretary of Defense for Health Affairs to (1) assess the extent to
which actions taken in response to MRSP have corrected medical
capability problems, (2) take steps to resolve other unsettled
problems, and (3) use the results of the MHSS 2020 project to guide
the focus of MRSP and service reengineering initiatives. 


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

In commenting on a draft of this report, DOD concurred with our
recommendations and agreed with the accuracy of the report.  DOD
stated that it was aggressively pursuing resolution of the problems
described in our report.  For example, through Health Affairs/Joint
Staff coordination, all of the missing Joint Staff implementation
plans have been developed.  DOD also commented that Health Affairs
has begun the process of assessing the extent to which actions taken
in response to MRSP have corrected medical capability problems.  From
these assessments, DOD will develop strategies for resolution of
unresolved problems. 

DOD provided some technical comments to our report and we
incorporated them into the text of our report where appropriate. 
DOD's comments appear in appendix I. 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :9

To obtain information for the report, we reviewed documents, reports,
and information relevant to the development and implementation of
MRSP, services' medical reengineering programs, and MHSS 2020
project.  We interviewed officials from the Office of the Assistant
Secretary of Defense for Health Affairs, Joint Staff and Office of
the Assistant Secretary of Defense for Reserve Affairs in Washington,
D.C; and the Offices of the Surgeons General at Navy and Air Force
Headquarters in Washington, D.C., and at the Army Medical Command in
San Antonio, Texas.  We also interviewed officials from the U.S. 
Central Command, Tampa, Florida; U.S.  Transportation Command, Scott
Air Force Base, Illinois; U.S.  Atlantic Command, Norfolk, Virginia;
Defense Medical Standardization Board, Fort Detrick, Maryland; and
the Marine Corps Combat Development Command, Quantico, Virginia. 

We reviewed the methodology used to develop MRSP and discussed its
reasonableness with several DOD officials.  We compared the content
of MRSP with the medical capability problem areas identified in our
work on Operation Desert Storm and with similar work conducted by the
DOD Inspector General.  We reviewed the detailed implementation plans
prepared by the primary action offices and identified the extent to
which tasks in the plans were reported to be completed, on schedule,
or delayed.  We did not weigh the relative importance of one task
against another.  We used the funding status information provided by
the primary action offices.  We discussed potential obstacles in
implementing MRSP with officials at the locations we visited. 

We obtained briefings from all of the services on their medical
reengineering programs and reviewed documentation concerning the
factors that led to the reengineering efforts, process used to
identify needed changes, extent to which the programs address common
goals for future medical capabilities, and current status of the
reengineering programs.  We interviewed agency officials regarding
any overlaps or inconsistencies among the services' reengineering
programs.  We examined the content of each services' reengineering
program to learn whether proposed changes were responsive to the
problems we and the DOD Inspector General had previously reported for
wartime medical capabilities. 

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


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

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 of the Marine Corps; and the
Director of the 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 II. 

Sincerely yours,

Mark E.  Gebicke
Director, Military Operations
 and Capabilities Issues




(See figure in printed edition.)APPENDIX I
COMMENTS FROM THE DEPARTMENT OF
DEFENSE
============================================================== Letter 



(See figure in printed edition.)


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix II


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

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


   NORFOLK FIELD OFFICE
-------------------------------------------------------- Appendix II:2

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


*** End of document. ***