oversight

Defense Health Care: Additional Analysis of Costs and Benefits of Potential Governance Structures Is Needed

Published by the Government Accountability Office on 2012-09-26.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States Government Accountability Office

GAO              Report to Congressional Committees




September 2012
                 DEFENSE HEALTH
                 CARE

                 Additional Analysis of
                 Costs and Benefits of
                 Potential Governance
                 Structures Is Needed




GAO-12-911
                                                 September 2012

                                                 DEFENSE HEALTH CARE
                                                 Additional Analysis of Costs and Benefits of
                                                 Potential Governance Structures Is Needed
Highlights of GAO-12-911, a report to
congressional committees




Why GAO Did This Study                           What GAO Found
Over the past decade, the cost of the            The Department of Defense’s (DOD) assessment of potential governance
MHS has grown substantially and is               options for its Military Health System (MHS) did not provide complete information
projected to reach nearly $95 billion by         on the options’ total cost impact and their strengths and weaknesses. As part of
2030 according to the Congressional              DOD’s assessment, it identified 13 potential governance options for the MHS and
Budget Office. As health care costs              included a limited analysis of the options’ estimated costs savings and their
consume an increasingly large portion            strengths and weaknesses. All of the options would create a shared services
of the defense budget, current DOD               concept to consolidate common services, such as medical logistics, acquisition,
leadership and Congress have                     and facility planning, under the control of a single entity. DOD selected an option
recognized the need to better control
                                                 that would create a defense health agency to, among other things, assume the
these costs. Section 716 of the
                                                 responsibility for creating and managing shared services, and leave the long-
National Defense Authorization Act for
Fiscal Year 2012 required DOD to
                                                 standing military chain of command intact with the services in control of the
submit a report analyzing potential              military hospitals. The National Defense Authorization Act (Act) for Fiscal Year
MHS governance options under                     2012 required DOD to submit a report to congressional committees that would,
consideration, and also required GAO             among other things, estimate the cost savings and analyze the strengths and
to submit an analysis of these options.          weaknesses of each option. Using key principles derived from federal guidance,
In response to this mandate, GAO                 including cost estimating and economic analysis documents, GAO determined
determined the extent to which DOD’s             that DOD could have provided more information on cost implications and
assessment provides complete                     strengths and weaknesses in its report to Congress. Specifically, DOD did not (1)
information on cost implications and             estimate implementation costs and comprehensive cost savings; (2) include a
the strengths and weaknesses of                  business case to support consolidating common services; or (3) include
potential MHS governance options. To             supporting quantitative data in its analysis of the options’ strengths and
conduct this review, GAO analyzed                weaknesses.
DOD’s governance report along with
supporting documents, and interviewed            •   DOD’s cost analysis for its potential MHS governance options was limited In
Task Force members.                                  that it did not include implementation costs and only estimated personnel
                                                     costs savings based on some potentially flawed assumptions, such as not
What GAO Recommends                                  using representative salaries to estimate personnel savings.
GAO recommends that DOD develop                  •   DOD did not develop a business case analysis and an implementation
(1) a comprehensive cost analysis for
                                                     strategy for its proposed shared services concept. A business case analysis
its potential MHS governance options,
                                                     would, among other things, define the services to be consolidated, cost to
(2) a business case analysis and
strategy for implementing its shared                 implement and efficiencies to be achieved and could support DOD’s
services concept, and (3) more                       assertion that implementing shared services could achieve efficiencies. DOD
complete analyses of the options’                    approved a shared services concept two other times since 2006, but it has
strengths and weaknesses. DOD                        yet to develop a business case analysis that would provide a data-driven
concurred with developing a business                 rationale for implementing the concept.
case analysis for its shared services
concept. DOD did not concur with the             •   DOD used a qualitative process with input from internal experts to assess the
other 2 recommendations, stating that                strengths and weaknesses of the potential governance structures. However,
further analysis would not alter its                 it did not balance this support with quantitative data as its criteria for
conclusions. GAO disagrees and                       assessing the strengths and weaknesses specified.
believes that more comprehensive
analysis will help to distinguish the            DOD officials stated that they did not provide comprehensive cost estimates or
differences among the costs and                  quantitative analysis of the options because an internal 90-day deadline to report
benefits of the options.                         back to the Deputy Secretary of Defense did not allow enough time. However,
                                                 the act requiring DOD to report to Congress was enacted subsequent to DOD’s
View GAO-12-911. For more information,           own internal assessment and did not establish a specific deadline. As a result,
contact Brenda S. Farrell at (202) 512-3604 or   DOD could have taken time to conduct a more comprehensive analysis before
farrellb@gao.gov.                                submitting its report.
                                                                                         United States Government Accountability Office
Contents


Letter                                                                                       1
                   Background                                                                4
                   DOD’s Preferred Option Generally Retains Command Structures
                     and Includes a Shared Service Concept                                 13
                   DOD’s Cost Analysis of Its Potential MHS Governance Options Was
                     Limited                                                               22
                   DOD Limited Its Assessment of the Options’ Strengths and
                     Weaknesses to a Qualitative Process                                   28
                   Conclusions                                                             34
                   Recommendations for Executive Action                                    34
                   Agency Comments and Our Evaluation                                      35

Appendix I         Scope and Methodology                                                   41



Appendix II        Detailed Description of the Potential Governance Structures and DOD’s
                   Assessment of Their Strengths and Weaknesses                          44
                   Defense Health Agency Governance Structures                             44
                   Unified Medical Command Governance Structures                           46
                   Single Service Governance Structures                                    49
                   Hybrid Governance Structures                                            50

Appendix III       Comments from the Department of Defense                                 53



Appendix IV        GAO Contact and Staff Acknowledgments                                   58



Related Products                                                                           59



Table
                   Table 1: Possible Implementation Cost and Cost Savings Categories
                            for DOD’s Preferred Defense Health Agency Governance
                            Structure                                                      27




                   Page i                                        GAO-12-911 Defense Health Care
Figures
          Figure 1: Distribution of Beneficiaries as of May 2012                                     6
          Figure 2: Governance Structure of the MHS as of August 2012                                7
          Figure 3: Timeline of Military Health System Governance Studies                            9
          Figure 4: Summary of Differences in Governance Elements for the
                   Potential Defense Health Agency, Unified Medical
                   Command, and the Single Service Governance Structures                            15
          Figure 5: Summary of Differences in Governance Elements for the
                   Potential Hybrid Governance Structures                                           16
          Figure 6: Criteria Used to Assess MHS Governance Options                                  29
          Figure 7: Frequency that the Criteria Were Listed as a Strength or
                   Weakness for Potential Governance Structures                                     33




          Abbreviations

          BRAC              Base Realignment and Closure
          DOD               Department of Defense
          MHS               Military Health System
          JTF CapMed        Joint Task Force National Capital Region Medical




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          Page ii                                                   GAO-12-911 Defense Health Care
United States Government Accountability Office
Washington, DC 20548




                                   September 26, 2012

                                   Congressional Committees

                                   Over the past decade, the cost of the Department of Defense’s (DOD)
                                   Military Health System (MHS) has grown substantially. DOD’s fiscal year
                                   2013 budget request for health care is almost $50 billion, 1 and is
                                   projected to reach about $95 billion by 2030. 2 Historical growth rates in
                                   the MHS have been significantly higher than the corresponding rates in
                                   the national economy. For example, from 2006 to 2011, DOD
                                   experienced annual growth rates of 6.2 percent for purchased care and
                                   contracts and 5.2 percent for direct care and administration, compared
                                   with a national rate of 3.3 percent. 3 As health care consumes an
                                   increasingly larger portion of the defense budget, DOD leadership
                                   recognizes the need to reduce duplication, overhead, and operate the
                                   most efficient health system possible. Under the current structure, the
                                   responsibilities and authorities for the management of the MHS and the
                                   medical services it provides to over 9.7 million beneficiaries are
                                   distributed among several organizations. Several past DOD studies have
                                   suggested that realigning the MHS governance structure could help
                                   control the increase in health care costs.

                                   Congressional leaders also have raised questions regarding rising military
                                   health costs and the MHS governance structure. For example, the House
                                   Armed Services Committee’s Print accompanying the Ike Skelton
                                   National Defense Authorization Act for Fiscal Year 2011 4 noted that DOD


                                   1
                                     DOD’s fiscal year 2013 budget request of $48.7 billion for its Unified Medical Budget
                                   includes $32.5 billion for the Defense Health Program, $8.5 billion for military medical
                                   personnel, $1.0 billion for military construction, and $6.7 billion set aside for the Medicare-
                                   Eligible Retiree Health Care Fund. The total excludes overseas contingency operations
                                   funds and certain transfers.
                                   2
                                     Congressional Budget Office, Long-term Implications of the 2013 Future Years Defense
                                   Program, Pub. No. 4458, July 2012.
                                   3
                                     The national rate refers to the comparable composite category of hospital care and
                                   physician and clinical services.
                                   4
                                     The Ike Skelton National Defense Authorization Act for Fiscal Year 2011 Pub. L. No.
                                   111-383 (2010) was not accompanied by a conference report. In lieu of a formal
                                   conference report and joint explanatory statement, House Committee on Armed Services
                                   Print No. 5 (December 2010) was reported to show congressional intent and maintain
                                   legislative history.




                                   Page 1                                                       GAO-12-911 Defense Health Care
had not yet developed a comprehensive plan to enhance quality,
efficiencies, and savings in the MHS, and it encouraged the Secretary of
Defense to evaluate the potential operational, organizational, and
financial benefits of a unified medical command. For the past 6 decades,
DOD and Congress have undertaken many studies to attempt to
determine the governance structure of the MHS, with many of these
studies recommending major organizational realignments. However, for
several years, GAO has highlighted a range of long-standing issues
surrounding the MHS and its efforts to reorganize its governance
structure. In 2005, we identified DOD’s health care system as an example
of a key challenge facing the U.S. government in the 21st century and an
area in which DOD could improve delivery of services by combining,
realigning, or otherwise changing selected support functions to achieve
economies of scale. 5 Additionally, in our March 2011 report on
opportunities to reduce potential duplication in government programs, we
noted that realigning DOD’s military medical command structures and
consolidating common functions could increase efficiencies and
significantly reduce costs. 6

In June 2011, the Deputy Secretary of Defense established a Task Force
to review various options for changes to the overall governance structure
of the MHS and of its multi-service medical markets and to provide a
report back within 90 days. 7 The Task Force submitted a report to the
Deputy Secretary of Defense in September of 2011. Further, the National
Defense Authorization Act for Fiscal Year 2012 required DOD to submit a
report to the congressional defense committees to include a description of
the alternative MHS governance structures developed and considered by
the Task Force; the goals to be achieved by restructuring or
reorganization and the principles upon which the goals are based; a
description of how each option would affect readiness, quality of care,
and beneficiary satisfaction; an explanation of the costs of each potential
option considered; an analysis of the strengths and weaknesses of each



5
 GAO, 21st Century Challenges: Reexamining the Base of the Federal Government,
GAO-05-325SP (Washington, D.C.: Feb. 2005).
6
  GAO, Opportunities to Reduce Potential Duplication in Government Programs, Save Tax
Dollars, and Enhance Revenue, GAO-11-318SP (Washington, D.C.: Mar. 1, 2011).
7
  Deputy Secretary of Defense Memorandum, Review of Governance Model Options for
the Military Health System (Jun. 14, 2011). Multi-service medical markets are areas in
which more than one DOD component provides military health care services.




Page 2                                                   GAO-12-911 Defense Health Care
option; and an estimate of the cost savings, if any, to be achieved by
each option compared to the MHS in place on December 31, 2011. No
deadline for DOD’s report was included in the statutory language.
Additionally, we were required to submit a subsequent report to the
congressional defense committees within 180 days from the date DOD
issued its report (March 2, 2012) reviewing, among other things, the cost
implications and strengths and weaknesses of DOD’s potential
governance structures. 8 In response to this mandate, we determined the
extent to which (1) DOD’s preferred governance option, and the other
options presented in its report, change the current structure of the MHS;
(2) DOD developed a cost analysis of its potential MHS governance
options; and (3) DOD’s assessment of the strengths and weaknesses of
its potential governance options is well supported and data-driven.

To determine how DOD’s preferred governance option and the other
options presented in its report would change the current structure of the
MHS, we obtained and reviewed the current MHS governance structure
including identifying key changes that have occurred since 1991 by
reviewing relevant legislative materials and DOD directives, as well as
interviewing knowledgeable DOD officials. We then compared the current
governance structure with each of the potential options by using the terms
of reference from the Task Force report. To determine the extent to which
DOD has developed a cost analysis of its potential MHS governance
options, we reviewed DOD’s analysis using key principles we derived
from cost estimating and budgeting guidance. 9 To apply those principles,
we reviewed DOD’s report, interviewed Task Force members concerning


8
  National Defense Authorization Act for Fiscal Year 2012, Pub. L. No. 112-81, § 716
(2011). The act also prohibits the Secretary of Defense from restructuring or reorganizing
the MHS until 120 days after we submit our report.
9
  We reviewed numerous federal guidance documents related to cost estimating,
accounting standards, economic analysis, and budgeting and identified key principles that
we believe can be applied to the evaluation of cost savings estimates. The guidance
documents we reviewed include: GAO Cost Estimating and Assessment Guide,
GAO-09-3SP (Washington, D.C.: Mar. 2, 2009); Office of Management and Budget
Circular No. A-11, Preparation, Submission and Execution of the Budget (Aug. 2011,
superseded by an August 2012 issuance); Federal Accounting Standards Advisory Board,
Statement of Federal Financial Accounting Standards 4 (June 2011); Department of
Defense Instruction 7041.3, Economic Analysis for Decisionmaking (Nov. 7, 1995); and
Department of Defense Financial Management Regulation 7000.14-R, Volume 4, Chapter
22, Cost Finding (May 2010). Although each of these documents may not apply to these
circumstances as a legal matter, we believe that they collectively contain broad themes
that can be applied to evaluating cost analyses.




Page 3                                                    GAO-12-911 Defense Health Care
             their analysis, and identified broad cost categories that should be
             considered in the course of implementing DOD’s governance
             transformation. We were unable to rely on DOD’s cost savings estimates
             because the estimates and their supporting data were insufficient in the
             key data elements needed to completely and accurately develop them as
             discussed in the findings section of this report. Finally, to determine the
             extent to which DOD’s assessment of the strengths and weaknesses of
             its potential governance options is well-supported and data driven, we
             obtained and reviewed the Task Force’s supporting documents including
             meeting minutes, briefing slides, and the voting template for the criteria
             and process used to formulate the strengths and weaknesses of the
             options. We also interviewed Task Force officials regarding their
             involvement in the process and how they formulated their assessments.
             For each of our objectives, we limited our review to the potential overall
             governance structures that the Task Force presented in its report. We did
             not specifically review the proposed changes to DOD’s multi-service
             medical markets or to the governance structure in place within the
             National Capital Region as presented in the Task Force report because
             we determined these proposed changes were outside the scope of our
             mandate. We conducted this performance audit from March 2012 through
             September 2012 in accordance with generally accepted government
             auditing standards. Those standards require that we plan and perform the
             audit to obtain sufficient, appropriate evidence to provide a reasonable
             basis for our findings and conclusions based on our audit objectives. We
             believe that the evidence obtained provides a reasonable basis for our
             findings and conclusions based on our audit objectives. For details on our
             scope and methodology, see appendix I.


             The MHS is a complex organization that provides health services to its
Background   beneficiaries across a range of care venues, from the battlefield to
             traditional hospitals and clinics at stationary locations. The current
             management of this large health system is spread over several
             organizations in order to meet its two-fold mission of ensuring
             servicemember readiness and delivering beneficiary care. Over the years
             many studies have been conducted to assess potential changes to the
             governance structure of the MHS.




             Page 4                                          GAO-12-911 Defense Health Care
Current Governance            DOD operates its own large, complex health system that employs almost
Structure of DOD’s Military   140,000 military, civilian, and contract personnel who work in medical
Health System                 facilities throughout the world to provide health care to approximately 9.7
                              million beneficiaries. 10 Operationally, the MHS has two missions:
                              supporting wartime and other deployments, known as the readiness
                              mission, and providing peacetime care, known as the benefits mission.
                              The readiness mission provides medical services and support to the
                              armed forces during military operations, including deploying medical
                              personnel and equipment throughout the world, and ensures the medical
                              readiness of troops prior to deployment. The benefits mission provides
                              medical services and support to members of the armed forces, retirees,
                              and their dependents. Beneficiaries fall into several different categories:
                              (1) active duty servicemembers and their dependents, (2) eligible National
                              Guard and Reserve servicemembers and their dependents, and (3)
                              retirees and their dependents or survivors. As of May 2012, active duty
                              servicemembers and their dependents represented 36.7 percent of the
                              beneficiary population, eligible National Guard and Reserve
                              servicemembers and their dependents represented 9.5 percent, and
                              retirees and their dependents or survivors made up the remaining 53.8
                              percent. See figure 1.




                              10
                                In addition to approximately 9.7 million beneficiaries, DOD also provides care and, in
                              some cases, rehabilitation for veterans as part of its coordination with the Department of
                              Veterans Affairs on health care services.




                              Page 5                                                     GAO-12-911 Defense Health Care
Figure 1: Distribution of Beneficiaries as of May 2012




Reporting to the Under Secretary of Defense (Personnel and Readiness),
the Assistant Secretary of Defense (Health Affairs) is the principal advisor
for all DOD health policies, programs, and force health protection
activities. The Assistant Secretary of Defense (Health Affairs) issues
policies, procedures, and standards that govern management of DOD
medical programs and has the authority to issue DOD instructions,
publications, and directive-type memorandums that implement policy
approved by the Secretary of Defense or the Under Secretary of Defense
(Personnel and Readiness). As the Director of the TRICARE
Management Activity, the Assistant Secretary of Defense (Health Affairs)
is also responsible for awarding, administering, and overseeing
approximately $24.4 billion in fiscal year 2012 funding for DOD’s
purchased care network of private sector civilian primary and specialty
care providers. Additionally, the Assistant Secretary of Defense (Health
Affairs) integrates the military departments’ budget submissions into a
unified medical budget that provides resources for MHS operations;
however, the military services have direct command and control of the
military hospitals and their medical personnel. See figure 2 for the current
organizational structure of the MHS.




Page 6                                                   GAO-12-911 Defense Health Care
Figure 2: Governance Structure of the MHS as of August 2012




                                        The care of the eligible beneficiary population is also spread across the
                                        Army, the Navy, and the Air Force, which deliver care at 56 inpatient
                                        facilities and hundreds of clinics. Both the Army and the Navy have
                                        medical commands headed by surgeons general. The Army’s portion of
                                        the fiscal year 2012 Unified Medical Budget’s funding is approximately
                                        $11.8 billion, and it manages 24 of the 56 inpatient facilities. Additionally,
                                        the Navy’s portion of the fiscal year 2012 Unified Medical Budget funding
                                        was approximately $6.4 billion. It manages 19 of the 56 inpatient facilities
                                        and provides medical support to the Marine Corps. Additionally, the Air
                                        Force’s portion of the fiscal year 2012 Unified Medical Budget’s funding is
                                        approximately $6.6 billion, and it manages 13 of the 56 inpatient clinics.
                                        The Air Force Surgeon General serves as medical advisor to the Air
                                        Force Chief of Staff and as functional manager of the Air Force Medical
                                        Service. Air Force hospitals and their personnel do not report to the Air
                                        Force Surgeon General, but directly to local line commanders. Each
                                        military department also recruits, trains, and funds its own medical




                                        Page 7                                            GAO-12-911 Defense Health Care
                         personnel to administer the medical programs and provide medical
                         services to beneficiaries.

                         Specifically for the management of Military Treatment Facilities within the
                         National Capital Region and the execution of related Base Realignment
                         and Closure (BRAC) actions in that area, an additional medical
                         organizational structure and reporting chain was established in 2007. 11
                         This structure is known as the Joint Task Force National Capital Region
                         Medical, and its Commander reports to the Secretary of Defense through
                         the Deputy Secretary of Defense. The two inpatient medical facilities in
                         the area, Walter Reed National Military Medical Center and Fort Belvoir
                         Community Hospital, were directed by the Deputy Secretary of Defense in
                         January 2009 to become joint commands. 12


Studies of Governance    As early as March 1949, the following recommendation was presented to
Structures for DOD’s     the Secretary of Defense:
Military Health System
                         “The Joint Chiefs of Staff recommend unanimously that the Secretary of Defense
                         immediately institute studies and measures intended to produce, for the support of the
                         three fighting services, a completely unified and amalgamated (single) Medical Service.” 13



                         As noted in DOD’s 2011 Task Force report, a long series of studies have
                         addressed the issue of DOD’s health care organization. Performed by
                         both internal and external boards, commissions, task forces, and other
                         entities, a number of these studies have recommended dramatic changes
                         in the organizational structure of military medicine. See figure 3 for a
                         timeline of MHS governance studies.




                         11
                            The 2005 BRAC Commission recommended that certain patient care activities at Walter
                         Reed Army Medical Center in Washington, D.C., be relocated to the National Naval
                         Medical Center in Bethesda, Maryland, and to a new community hospital at Fort Belvoir,
                         Virginia.
                         12
                           According to DOD, as of August 2012, these hospitals were operating on an interim
                         manning document.
                         13
                           Department of Defense, Review of the Department of Defense Organization for Health
                         Care, March 1991.




                         Page 8                                                    GAO-12-911 Defense Health Care
Figure 3: Timeline of Military Health System Governance Studies




                                        Although many of these studies favored a unified system or a stronger
                                        central authority to improve coordination among the services, major
                                        organizational change has historically been resisted by the military
                                        services in favor of the retention of their respective independent health
                                        care systems. In 1995, we reported that interservice rivalries and
                                        conflicting responsibilities, hindered improvement efforts, 14 and noted that
                                        the services’ resistance to changing the way military medicine is
                                        organized is based primarily on the grounds that each service has unique
                                        medical activities and requirements.




                                        14
                                          GAO, Defense Health Care: Issues and Challenges Confronting Military Medicine,
                                        GAO/HEHS-95-104 (Washington, D.C.: Mar. 22, 1995).




                                        Page 9                                                 GAO-12-911 Defense Health Care
Overview of DOD’s 2011   In June 2011, with the pending completion of the consolidation of medical
Task Force and Its       facilities and functions in the National Capital Region undertaken by DOD
Potential Governance     in response to 2005 BRAC Commission recommendations, the Deputy
                         Secretary of Defense recognized that a final decision concerning the
Options                  governance of military health care in the capital region needed to be
                         made. This need for a decision provided an opportunity to address the
                         desired end-state governance structure of the entire MHS. Furthermore,
                         in light of the considerable, long-term fiscal challenges the nation faces,
                         and the 2010 comprehensive review established by the then-Secretary of
                         Defense to inform future decisions about spending on national security,
                         the Deputy Secretary of Defense wrote that it was important to ensure
                         that MHS was organized in a way that curtails expenses and achieves
                         savings to the greatest extent possible in meeting its mission.

                         As a result, in June of 2011, the Deputy Secretary of Defense established
                         an internal task force to conduct a review of the current governance
                         structure of the MHS. The Task Force was directed to evaluate options
                         for the long-term governance of the MHS as a whole and for the
                         governance of multi-service medical markets, to include the National
                         Capital Region and to provide a report within 90 days detailing the relative
                         strengths and weaknesses of each option evaluated as well as
                         recommendations. The Deputy Secretary of Defense designated the co-
                         chairs of the Task Force as the Deputy Assistant Secretary of Defense
                         (Force Health Protection and Readiness) and the Joint Staff Surgeon.
                         The Task Force also contained representatives from the military
                         services, 15 the Joint Chiefs of Staff, the DOD Comptroller, the Cost
                         Assessment and Program Evaluation Office, and the Under Secretary of
                         Defense (Personnel and Readiness). In addition to this membership, the
                         co-chairs included representatives from the Office of the Deputy
                         Secretary of Defense, the DOD Office of General Counsel, Legislative
                         Affairs, and Administration and Management as advisors to the Task
                         Force.

                         Potential Governance Structures—DOD’s report, submitted to the Deputy
                         Secretary of Defense in September of 2011 and later to Congress in
                         response to section 716 of the National Defense Authorization Act for
                         Fiscal Year 2012, presented 13 potential governance structures for the



                         15
                           The Task Force subsequently added a representative from the Marine Corps to the
                         Department of the Navy delegation.




                         Page 10                                                GAO-12-911 Defense Health Care
overall MHS, with other options for governance of multi-service medical
markets and the National Capital Region. The potential options were
variations of the following three governance structures: 16

•    The defense health agency governance structures would create a
     combat support agency led by a 3-star flag officer (Lieutenant General
     or Vice Admiral) who would report to the Assistant Secretary of
     Defense (Health Affairs). This agency would be focused on
     consolidating and delivering a set of shared health care support
     services. DOD presented variations of a defense health agency which
     would (1) leave management of the Military Treatment Facilities with
     the military services, (2) place the management of the Military
     Treatment Facilities under the control of the defense health agency, or
     (3) create hybrid structures by pairing the agency with other options
     such as a unified medical command.

•    The unified medical command governance structures would create
     a unified functional combatant command led by a 4-star flag officer
     (General or Admiral) who would report to the Secretary of Defense.
     The command would exercise direction and control over the entire
     MHS but would do so either through (1) service components, (2)
     geographic regions, (3) a subordinate health care command, or (4)
     various hybrid governance structures pairing the unified medical
     command with other options such as a designated single service
     structure.

•    Finally, the single service governance structures would place overall
     control of the MHS under one designated military department
     Secretary, who would report to the Secretary of Defense. However,
     each of the services would continue to organize, train, and equip their
     respective forces. The Military Treatment Facilities report to the
     designated military department Secretary through a variety of local
     and regional commands combinations.
See appendix II for a more detailed description of DOD’s potential
governance options.

Task Force Voting Process—Through the course of 20 formal meetings,
the Task Force members evaluated 13 potential overall governance


16
  These three structures are in addition to the current MHS structure, which the Task
Force included in the 13 options presented in the report.




Page 11                                                   GAO-12-911 Defense Health Care
structures by first establishing criteria for evaluation and developing a
system to weight the criteria to reflect their relative importance. After
formulating criteria, the Task Force discussed each potential governance
structure in detail. Following discussion, the individual Task Force
members voted on the governance structures by scoring them according
to the criteria. The member score was then adjusted by the weights
established by the Task Force, and the governance structures were
ranked according to the final, weighted score. The Task Force held five
voting rounds on the governance options throughout the 90 days allotted
to the review process (rather than holding a single vote at the end of the
review). Using this method, the Task Force evaluated the potential
structures in “head-to-head” voting rounds, until the governance option
that the Task Force believed was the highest ranking was determined.

Task Force Results—The Task Force provided the Deputy Secretary of
Defense with a report and a recommendation as to which course of action
to follow for changing the governance structure of the overall MHS, the
multi-service medical markets, and specifically, the National Capital
Region. For the overall MHS, the Task Force’s recommendation was to
pursue the formation of a defense health agency which would consolidate
common shared services 17 in support of the three military departments
and to leave the medical components of the military departments as they
are currently. The rationale for this action, according to the Task Force
report, would allow DOD to create shared services, common business
and clinical practices under one leader without large-scale changes to the
MHS at this time. According to the Task Force report, pursuing this
preferred option would not preclude subsequent decisions by the
Department to implement more sweeping changes in the future and was
considered an appropriate incremental next step to improving MHS
governance and providing a structure to rein in healthcare costs.




17
  According to DOD a shared services concept is a combination of common services
performed across the medical community, such as medical logistics, facility planning,
medical education and training, health information technology, and medical research and
development.




Page 12                                                  GAO-12-911 Defense Health Care
                           DOD’s preferred option would create a defense health agency that would
DOD’s Preferred            assume the responsibility for shared services in the MHS with military
Option Generally           hospitals remaining under the control of the services while other potential
                           options represent larger scale changes. In addition, DOD’s preferred
Retains Command            option would include implementing a shared services concept, which was
Structures and             common to all of its governance options; however, DOD did not develop a
Includes a Shared          business case analysis that would provide a data-driven rationale for
                           implementing the concept.
Service Concept
DOD’s Preferred Option     DOD’s preferred option creates a defense health agency that would
Creates a New Agency but   report to the Assistant Secretary of Defense (Health Affairs) and would
Maintains Established      consolidate and deliver shared services in the MHS while services would
                           maintain control of their military hospitals. DOD presented a wide range of
Military Chains of         governance structures in its report, such as creating another unified
Command                    functional combatant command or establishing a single service in charge
                           of all medical operations. However, DOD’s preferred option does not
                           require complex changes in long-established military chains of command
                           like some other structures would. As discussed earlier, currently the
                           Army, the Navy, and the Air Force manage their own personnel,
                           hospitals, and medical operations. The Assistant Secretary of Defense
                           (Health Affairs) exercises authority, direction, and control over the policies
                           and resources of the MHS, but does not have command and control over
                           the military hospitals or over the respective military departments’ medical
                           personnel. Over the years, DOD has shifted certain responsibilities and
                           authorities among various MHS officials, as seen in the establishment of
                           the Assistant Secretary of Defense (Health Affairs) authority over the
                           Defense Health Program in 1991 and the TRICARE Management Activity
                           in 1998, both of which remain part of the current MHS. In 1991, the
                           Defense Health Program was established as the result of a study of
                           governance options for the MHS to address concerns about recurring
                           funding crises and concerns over the inconsistent distribution of health
                           care services and benefits among the different military departments. In
                           1992, Department of Defense Directive 5136.1 assigned responsibility for
                           the program to the Assistant Secretary of Defense (Health Affairs). Later,
                           the TRICARE Management Activity was created to reduce duplication
                           within management of the MHS and transfer the direct management of
                           several functions away from the Assistant Secretary of Defense (Health
                           Affairs) to allow that position to concentrate on major policy and Defense
                           Health Program related issues and initiatives. Together, all of these
                           entities and their responsibilities have evolved into the current MHS
                           governance structure.



                           Page 13                                           GAO-12-911 Defense Health Care
The Task Force reviewed multiple versions of three basic governance
structures—defense health agency, unified medical command, and single
service. The options’ primary differences from the current structure of the
MHS occur mainly in three particular areas of roles and responsibilities—
overall control, budgetary authority, and control of personnel. DOD’s
preferred governance option is a defense health agency with military
hospitals remaining under the control of the military services. The unified
medical command options would assign the services’ medical assets to a
functional combatant command. Lastly, the single service options would
assign these assets to a single military service. Figure 4 summarizes
variations of these three structures and the current structure as it has
evolved over the years, while figure 5 presents a number of hybrid
models also considered by the Task Force, such as an option which
includes a unified medical command sharing responsibilities with a
defense health agency.




Page 14                                         GAO-12-911 Defense Health Care
Figure 4: Summary of Differences in Governance Elements for the Potential Defense Health Agency, Unified Medical
Command, and the Single Service Governance Structures




                                        Page 15                                             GAO-12-911 Defense Health Care
Figure 5: Summary of Differences in Governance Elements for the Potential Hybrid Governance Structures




                                        Page 16                                             GAO-12-911 Defense Health Care
•    Overall control – determines policy making authority, dispute
     resolution, and lines of accountability. Under the current MHS
     structure, the Assistant Secretary of Defense (Health Affairs)
     exercises authority, direction, and control of policy and resources, but
     DOD noted that in practice, this structure fails to take advantage of
     consensus opportunities to more rapidly implement common business
     processes. DOD’s preferred option of a defense health agency with
     military hospitals remaining under the control of the services would
     establish a military-led combat support agency organized under the
     Assistant Secretary of Defense (Health Affairs) that would have
     authority, direction, and control of shared services, health plan
     management, other strategic areas, while another version of this
     option would assign the proposed defense health agency control of
     military hospitals. The unified medical command options would place
     authority, direction, and control of the MHS with a functional
     combatant commander, along with direct responsibility for execution
     of health care services. This option would mark a departure from the
     current separation of these responsibilities among the three military
     services. The single-service options would assign responsibility for the
     MHS as a whole to a designated military service Secretary who would
     also command all military hospitals— a departure from the current
     arrangement of split responsibility between the Assistant Secretary of
     Defense (Health Affairs) and the military departments. Under all
     options, the Assistant Secretary of Defense (Health Affairs) would
     retain a policy-making role.

•    Budgetary authority – determines the organizational entity or entities
     with responsibility over the Defense Health Program appropriation. In
     2007, the Defense Health Board stated in its report, Task Force on
     the Future of Military Health Care, 18 that the MHS does not function
     as a fully integrated health care system and this lack of integration
     diffuses accountability for fiscal management and results in
     misalignment of incentives. The current governance structure vests
     overall budgetary authority with the Assistant Secretary of Defense
     (Health Affairs), who allocates funds to the services to execute their
     respective budgets. The Assistant Secretary of Defense (Health
     Affairs) does not have command and control over the military
     hospitals or over the respective military departments’ medical



18
  Defense Health Board, Task Force on the Future of Military Health Care (December
2007).




Page 17                                                GAO-12-911 Defense Health Care
    personnel. DOD’s preferred option of a defense health agency with
    military hospitals remaining under the control of the services would
    not alter this aspect of the current governance structure. An
    alternative potential option of a defense health agency with the
    military hospitals under the agency’s control would assume direct
    control of the Defense Health Program appropriation. Like the latter
    option, the unified medical command options would consolidate
    budgetary authority with a single official, a functional combatant
    commander, along with direct responsibility for the execution of health
    care, and would mark a departure from the current separation of these
    responsibilities. Similarly, the single-service options would streamline
    budgetary authority by vesting all such authority with a designated
    military service Secretary.

•   Personnel control – determines which entity has management and
    supervisory responsibility over the personnel working within the MHS.
    Historically, military services have exercised command and control
    over their own medical personnel, and Task Force members told us
    that control over the medical personnel was a sensitive issue in their
    discussions. DOD’s preferred option of a defense health agency with
    military hospitals remaining under the control of the services would
    allow the services to maintain control over their own personnel. An
    alternative potential option of a defense health agency with the
    military hospitals under the agency’s control would allow the agency
    to take control of personnel not assigned to deployable units. The
    unified medical command options vary on the level of authorities
    retained over personnel, as some options assign control of all forces
    to the unified medical command, and others assign control of only
    some personnel to the unified medical command. The single service
    options provide some level of control of all personnel to the
    designated single military service in charge of the MHS, with
    variations of this option related to the assignment of the deployable
    medical personnel assigned to their respective military services.

DOD’s potential governance options would have different effects on multi-
service medical market governance, which is the management of medical
care in a geographic area where more than one service operates Military
Treatment Facilities through a common business plan and coordination of
resources. For example, a single service option would make such
coordination unnecessary, while it still might be required under a unified
medical command. In its report, DOD cites the main weakness of the
current governance of multi-service markets as the failure to fully
leverage the medical capabilities across service boundaries in a given
market to achieve efficiencies. According to DOD officials, DOD’s


Page 18                                          GAO-12-911 Defense Health Care
preferred option of a defense health agency would allow the department
to implement an enhanced management structure for the multi-service
medical markets that would drive such efficiencies while avoiding
complex changes to long-established military chains of command.
According to DOD’s report, the authorities of the multi-service market
managers would be expanded to include responsibility for developing a 5-
year business plan, budgetary authority for the entire medical market, and
the authority to direct personnel to work in other locations within the
market on a short-term basis, among other authorities. However, DOD’s
current effort is not its first attempt at improving multi-service medical
market governance. As its report notes, DOD has experimented with
different approaches to multi-service medical markets over the past 25
years, including the 2003 establishment of Senior Market Managers
responsible for coordinating the development of a single business plan for
all Military Treatment Facilities in each such market. In 2006, the Deputy
Secretary of Defense approved the implementation of an alternative to
wholesale changes in the structure of the MHS, which included seven
targeted governance initiatives. Among other things, the initiatives
included the establishment of governance structures for two multi-service
medical markets, San Antonio and the National Capital Region, as well as
the creation of governance structures that consolidate command and
control of military treatment facilities in other multi-service medical
markets. 19 As we reported in 2012, DOD established these structures in
San Antonio and the National Capital Region, but had made no changes
to the governance structures of other multi-service markets. 20 Several
senior DOD officials noted that while they recognize there are efficiencies
to be gained in multi-service markets, they expressed reservations
concerning the details of DOD’s plans for reforming such markets. One
senior DOD official highlighted challenges that may arise in their
operation, such as the control of medical personnel to support
deployments and other missions and coordination of market business
plans with the services’ priorities.




19
   Action Memorandum for the Deputy Secretary of Defense, Joint/Unified Medical
Command (J/UMC) Way Ahead (Nov. 27, 2006).
20
   GAO, GAO-12-224, Applying Key Management Practices Should Help Achieve
Efficiencies within the Military Health System, GAO-12-542 (Washington, D.C.: Apr 12,
2012).




Page 19                                                  GAO-12-911 Defense Health Care
DOD Did Not Present a        DOD did not present a business case analysis for proceeding with its
Business Case Analysis for   shared services concept 21 common to all of the proposed governance
Its Shared Services          structures, including an estimate of costs to merge shared services
                             functions, operational savings to be accrued, or the likely timeframe in
Concept
                             which this service consolidation would achieve savings. As we have
                             previously reported, a business-case analysis can provide a data-driven
                             rationale for why an agency is undertaking a consolidation initiative, such
                             as a shared services concept since consolidation is beneficial in some
                             situations and not in others, and so a case-by-case analysis is
                             necessary. 22 DOD has twice proposed this shared services concept in the
                             past, which would consolidate areas such as information technology,
                             contracting, and public health under one entity. DOD first proposed
                             implementation of a shared services concept in 2006 as part of a series of
                             seven different incremental governance initiatives adopted as an
                             alternative to wholesale changes in the structure of the MHS. Specifically,
                             implementation of the initiative would have created a Joint Military Health
                             Service Directorate under a joint senior flag officer reporting to the
                             Assistant Secretary of Defense (Health Affairs), a structure not unlike
                             DOD’s preferred option of a Defense Health Agency for its current review
                             of MHS governance. At the time, we recommended that DOD needed to
                             demonstrate a sound business case, including an analysis of benefits,
                             costs, and risks, for proceeding with its seven initiatives, and DOD
                             concurred with our recommendation. 23 Further, we later reported that
                             DOD had not developed such estimates, and the Assistant Secretary of
                             Defense (Health Affairs) had not provided guidance on how and when to
                             complete these initiatives. 24 In 2012, we also reported that in the prior
                             calendar year, DOD approved a plan to reorganize the TRICARE
                             Management Activity and establish a shared services division with a new
                             Military Health System Support Activity as part of the former Secretary of



                             21
                               According to DOD a shared services concept is a combination of like common services
                             across the medical community, such as medical logistics, facility planning and
                             construction, health information technology, and medical research and development.
                             22
                                GAO, Streamlining Government: Questions to Consider When Evaluating Proposals to
                             Consolidate Physical Infrastructure and Management, GAO-12-542 (Washington, D.C.:
                             May 23, 2012).
                             23
                               GAO, Defense Health Care: DOD Needs to Address the Expected Benefits, Costs, and
                             Risks for Its Newly Approved Medical Command Structure, GAO-08-122 (Washington,
                             D.C.: Oct. 12, 2007).
                             24
                                  GAO-11-318SP. GAO-12-224.




                             Page 20                                                GAO-12-911 Defense Health Care
Defense’s effort to increase efficiencies and reduce costs with the
department. 25 As a result of this effort, DOD reduced the fiscal year 2012
Defense Health Program budget request anticipating the establishment of
the Military Health System Support Activity, but the initiative was put on
hold pending the results of the Task Force report.

In addition to a data-driven analysis, our body of work on organizational
mergers, acquisitions, and other transformations has shown that agencies
should apply essential change management practices such as active,
engaged leadership of top leaders and a dedicated implementation team
to ensure the continued attention needed for a transformation to be
sustained and successful, among others. 26 We reported in 2012 that in
the implementation of its 2006 governance initiatives, including efforts to
establish a shared services directorate, DOD did not establish an
effective and ongoing communication strategy, did not establish a
dedicated implementation team, and top leadership did not provide the
sustained direction needed to maintain progress. 27 Moreover, we also
have previously reported on the challenges that other federal agencies
have faced in attempting to specifically implement shared services. For
example, in December 2005, the Department of Homeland Security
(DHS) halted its eMerge2 program, which was expected to integrate
financial management systems across the entire department and address
financial management weaknesses, after DHS had spent about $52
million, according to officials. 28 We noted our concern that moving
forward, DHS did not have a fully developed financial management
strategy and plan for the integration of its financial management systems
and shared services, such as information technology hosting, business
process services, and application management services.

DOD’s report does not estimate the costs to implement a shared services
concept or an implementation timeline. Also, while DOD estimated a
projected savings of 330 full-time personnel equivalents for implementing


25
     GAO-12-224.
26
  GAO, Highlights of a GAO Forum: Mergers and Transformation: Lessons Learned for a
Department of Homeland Security and Other Federal Agencies, GAO-03-293SP
(Washington, D.C.: Nov. 14, 2002).
27
     GAO-12-224.
28
  GAO, Homeland Security: Departmentwide Integrated Financial Management Systems
Remain a Challenge, GAO-07-536 (Washington, D.C.: June 21, 2007).




Page 21                                               GAO-12-911 Defense Health Care
                       this concept, it did not estimate potential savings from consolidating
                       common services. According to DOD officials, DOD’s preferred option of
                       a defense health agency is a significant change for the MHS because it
                       would allow the department to implement shared services in order to drive
                       the adoption of common business and clinical practices and achieve
                       efficiencies while not requiring complex changes to long-established
                       military chains of command. However, under the current governance
                       structure, the Assistant Secretary of Defense (Health Affairs) has the
                       broad authority that could allow for the implementation of shared support
                       services across the MHS. As noted above, DOD has developed
                       proposals to exercise such authority in the past, but such proposals have
                       never been implemented. Further, DOD has not developed a business
                       case analysis for its shared services concept since it was first proposed in
                       2006. Until DOD develops a more detailed business case analysis, it
                       lacks a data-driven rationale and a strategy for proceeding with the
                       implementation of this concept.


                       DOD took certain steps to develop a cost analysis for its potential MHS
DOD’s Cost Analysis    governance options, but we found it to be limited because it (1) did not
of Its Potential MHS   include an estimate of implementation costs, (2) reflected only personnel
                       cost savings, and (3) was based on some potentially flawed assumptions.
Governance Options     DOD initiated a review of potential governance structures to assess
Was Limited            possible changes that it anticipated could result in improved effectiveness
                       and cost savings within the MHS. To aid its assessment, DOD included
                       many internal stakeholders from across the department in the Task Force
                       to solicit varying opinions and perspectives in the deliberations. As part of
                       this process, the Task Force used a number of methods to develop
                       estimates of the required number of full-time equivalent positions for the
                       headquarters of each potential governance structure. To develop its cost
                       savings estimates, the Task Force then translated these estimates of the
                       number of required personnel into costs by multiplying the number of full-
                       time equivalent positions by an average salary for civilian employees. The
                       Task Force did not attempt to estimate savings other than in the area of
                       headquarters personnel. Based on key principles we derived from cost




                       Page 22                                          GAO-12-911 Defense Health Care
estimating and budgeting guidance, 29 we identified two elements needed
to ensure a reasonable basis for cost savings estimates: (1) inclusion of
all significant costs and key assumptions and (2) use of reliable data.
However, several aspects of DOD’s cost analysis fell short of these
principles for the following reasons.

•     DOD did not estimate implementation costs. The Task Force’s report
      does not include an estimate of implementation costs for any of its 13
      governance options. We have previously reported that, in some
      instances, up-front investments are needed to yield longer-term
      savings. 30 The results of the implementation of the 2005 BRAC
      recommendations provide useful insight concerning the effect of
      implementation costs on the net impact of major transformations. For
      example, the estimate of the 20-year net present value 31 for the
      relocation of medical command headquarters changed from a
      projected net savings of $316.3 million to a net cost of $105.9 million.
      According to officials, projected increases are the result of the
      decision to lease a building, as opposed to the original plan to
      renovate an existing building or build a new facility. 32 Over the course
      of BRAC implementation, DOD’s one-time implementation costs



29
   We reviewed numerous federal guidance documents related to cost estimating,
accounting standards, economic analysis, and budgeting and identified key principles that
we believe can be applied to the evaluation of cost savings estimates. The guidance
documents we reviewed include: GAO Cost Estimating and Assessment Guide,
GAO-09-3SP; Office of Management and Budget Circular No. A-11, Preparation,
Submission and Execution of the Budget (Aug. 2011, superseded by an August 2012
issuance); Federal Accounting Standards Advisory Board, Statement of Federal Financial
Accounting Standards 4 (June 2011); Department of Defense Instruction 7041.3,
Economic Analysis for Decisionmaking (Nov. 7, 1995); and Department of Defense
Financial Management Regulation 7000.14-R, Volume 4, Chapter 22, Cost Finding (May
2010). Although each of these documents may not apply to these circumstances as a
legal matter, we believe that they collectively contain broad themes that can be applied to
evaluating cost analyses.
30
     GAO-12-542.
31
  Net present value is a financial calculation that accounts for the time value of money by
determining the present value of future savings minus up-front investment costs over a
specific period of time. Determining net present value is important because it illustrates
both the up-front investment costs and long-term savings in a single amount. In the
context of BRAC implementation, net present value is calculated for a 20-year period from
2006 through 2025.
32
   GAO, Military Base Realignments and Closures: Updated Costs and Savings Estimates
from BRAC 2005, GAO-12-709R (Washington, D.C.: Jun. 29, 2012).




Page 23                                                    GAO-12-911 Defense Health Care
      increased 53 percent, from the $21 billion originally estimated by the
      BRAC Commission to about $32.2 billion, 33 while the 20-year net
      present value of savings decreased 72 percent, from $35.6 billion
      originally estimated by the BRAC Commission to $9.9 billion. 34 The
      Cost of Base Realignment and Closure Model provides a number of
      implementation cost categories that may be relevant to health care
      reorganization, including personnel severance, moving costs, and
      military construction. Military construction costs are particularly
      important, as our analysis of the implementation of the 2005 BRAC
      recommendations found that such expenses were largely responsible
      for the overall increase in implementation costs. Task Force officials
      told us that they did not attempt to develop implementation cost
      estimates for the various options, and that they intend to develop an
      implementation cost estimate only for DOD’s preferred option as part
      of the implementation process. Similarly, in the course of the 2006
      review of possible changes to MHS governance, DOD approved
      seven initiatives to improve medical governance without conducting a
      comprehensive cost-benefit analysis. GAO recommended that DOD
      needed to demonstrate a sound business case, including an analysis
      of benefits, costs, and risks, for proceeding with its preferred medical
      governance concept, and DOD concurred. However, in 2011, we
      reported that DOD had not developed such estimates. 35

•     DOD restricted its estimates to personnel savings. DOD’s cost
      analysis of potential savings for its governance options was limited to
      changes in headquarters personnel levels and excluded other
      possible areas of savings. By limiting its analysis of savings for all of
      the governance options to changes in headquarters personnel levels,
      DOD’s savings estimates do not consider the impact of headquarters
      reorganization on the larger health system. In its 2006 report on MHS
      governance, 36 CNA’s Center for Naval Analyses presented additional
      areas of potential savings which the 2011 Task Force report did not
      explore. Although CNA’s estimates are 6 years old and do not reflect
      such changes in the MHS as the consolidation of health care in the


33
     Calculation and amounts in 2005 constant dollars.
34
     GAO-12-709R.
35
     GAO-11-318SP.
36
  CNA Center for Naval Analyses, Cost Implications of a Unified Medical Command,
2006.




Page 24                                                  GAO-12-911 Defense Health Care
    National Capital Region, the study provides several categories for
    potential savings beyond headquarters personnel. For example,
    health care operations savings could be accrued through
    administrative consolidation between large medical facilities which
    perform responsibilities on behalf of smaller clinics in the same
    geographic area. CNA reported that by bridging current service
    administrative boundaries which require the smaller clinics to report to
    larger facilities of the same service, potential savings could be
    accrued by designating a single facility in a geographic area to
    perform technical, legal, and administrative functions on behalf of all
    nearby clinics, regardless of service affiliation. In addition, governance
    reorganization may provide an opportunity to reduce infrastructure
    costs, and as the CNA report notes, the timeline for realizing cost
    savings could influence the amount of possible short- and long-term
    savings. The difference in the areas of cost savings considered and
    methodological approaches could explain the varying results of CNA
    and DOD’s analyses. For example, DOD estimated a net cost
    increase for a unified medical command option, while CNA estimated
    a net cost savings for the same option in its 2006 study. As noted
    earlier, although DOD’s preferred option assumes that DOD would
    achieve some personnel efficiencies due to greater use of shared
    services, DOD did not estimate the operational savings it expects,
    such as savings from consolidated contracts.

•   DOD used several potentially flawed assumptions in estimating
    headquarters personnel savings. DOD used several potentially flawed
    assumptions in estimating its headquarters personnel savings, and
    therefore it cannot be assured that DOD’s methods to estimate such
    savings produced reliable results. First, DOD estimated the size of a
    unified medical command by using Joint Task Force National Capital
    Region Medical (JTF CapMed) headquarters as an example of a
    unified medical command on a small scale. DOD estimated that given
    this command performs 10 percent of MHS operations with 150
    personnel, a unified medical command would require a minimum of
    1,500 personnel. However, DOD did not present evidence that 150
    personnel is the most efficient number of staff for JTF CapMed, and
    the assumption concerning the relationship between the number of
    staff at JTF CapMed and a unified medical command is questionable
    because economies of scale could create efficiencies, therefore
    requiring fewer personnel. Moreover, the report assumes such
    economies of scale in its estimate of personnel savings from shared
    services functions. Second, DOD used the services’ execution of the
    Defense Health Program’s Operations and Maintenance budget to
    determine the most efficient staffing requirements for service support


Page 25                                           GAO-12-911 Defense Health Care
      and regional commands. While these commands currently execute
      only their respective services’ portion of the budget, DOD estimated
      the number of full-time equivalents each of these commands would
      require if charged with executing the entire budget. However, in its
      report, DOD undermines the credibility of this method by citing
      numerous weaknesses, and characterized this approach as “not a
      credible predictor of staffing requirements.” Third, DOD determined
      the cost of the potential options’ personnel requirements by
      multiplying an average of TRICARE Management Activity civilian
      compensation by the number of staffing requirements. However, this
      figure excluded military personnel, whose compensation is markedly
      different from that of civilian personnel.

Task Force officials stated that the internal 90-day deadline required by
the Deputy Secretary of Defense for the Task Force to complete its report
did not allow for a detailed analysis of implementation costs or a more
thorough review of possible cost savings, and that this time period also
limited the practicality of more detailed analysis. However, the National
Defense Authorization Act for Fiscal Year 2012, which required a report
on MHS governance options to be submitted to the congressional
defense committees, was passed approximately 3 months after the Task
Force completed its review and contained no specific deadline for DOD to
submit its report. DOD chose to submit the report developed by the Task
Force in response to the Deputy Secretary of Defense’s direction, along
with an additional cost analysis in response to the statutory requirement.
However, DOD could have conducted additional analysis before
submitting its report to the congressional defense committees.

Given the concerns outlined above, DOD has not comprehensively
assessed the net costs of the various governance options. As we
reported in 2007, such information is critical to making data-informed
decisions about the structure of the MHS, especially in light of the nation’s
current fiscal challenges. 37 Past transformation experiences, such as the
BRAC process, and prior reports on MHS governance, such as the 2006
CNA study, could provide a starting point for DOD in the consideration of
possible implementation costs, cost savings areas, and methods of
estimating such cost data. DOD has selected its preferred structure, a
Defense Health Agency with the Military Treatment Facilities remaining
under the services, without the benefit of an inclusive cost analysis which


37
     GAO-08-122.




Page 26                                          GAO-12-911 Defense Health Care
explores these areas. Table 1 provides possible implementation cost and
cost savings categories from BRAC and the 2006 CNA study and
available estimates for DOD’s preferred defense health agency
governance option as provided in their report.

Table 1: Possible Implementation Cost and Cost Savings Categories for DOD’s
Preferred Defense Health Agency Governance Structure

    Category                                                  Cost/Savings (dollars, millions per year)
    Implementation Costs
       Personnel severance                                    Not estimated
       Moving                                                 Not estimated
       Military construction                                  Not estimated
       Information technology                                 Not estimated
    Total Implementation Costs                                Not estimated
    Cost Savings
                                                                              a
       Shared Services                                        Not estimated
       Health care operations                                 Not estimated
       Reduced Infrastructure                                 Not estimated
                                                                      b
       Personnel                                              $46.5
    Total Cost Savings                                        Not estimated
       Net Cost/Savings                                       Not estimated
Source: GAO analysis and DOD MHS governance cost estimates.
a
 These savings should include the net of any implementation costs and anticipated savings
associated with the creation of the shared services part of the Defense Health Agency.
b
 We determined that this cost savings estimate is not reliable because DOD did not use estimating
methods which produced reliable results.


Prior attempts to proceed with MHS reorganization without the benefit of
reliable estimates of implementation costs and cost savings demonstrate
the effects of such an approach. In 2007, DOD did not conduct a
comprehensive cost-benefit analysis, including an analysis of benefits,
costs, and risks, for proceeding with its preferred medical governance
concept at that time, which consisted of seven different incremental
governance initiatives. 38 At the time, DOD concurred with our
recommendation that they develop such an analysis, but we reported in




38
     GAO-08-122.




Page 27                                                                   GAO-12-911 Defense Health Care
                            2011 that it had not done so. 39 Additionally, in 2012, we reported that
                            DOD had documented estimated financial savings for only one of those
                            seven governance initiatives while at least one other one had an
                            estimated cost increase. 40 In the absence of an inclusive and reliable cost
                            analysis, DOD’s current effort may produce similar results.


                            DOD used a qualitative process to support its assessment of the
DOD Limited Its             strengths and weaknesses of the 13 potential governance options
Assessment of the           presented in its report, but did not balance this support with quantitative
                            data. We recognize the use of quantitative data is a key component of
Options’ Strengths          study quality, and DOD’s criteria calls for assessing the options based on
and Weaknesses to a         quantitative data. Also, DOD did not mention in its report some of the
Qualitative Process         criteria it identified as most important for assessing the governance
                            options because they asserted that no option that adversely affected
                            these two criteria would be recommended.


DOD’s Assessment            DOD used a deliberative and qualitative approach to assess the strengths
Gathered Significant        and weaknesses of the 13 potential governance structures presented in
Qualitative Information     its report that included developing and applying criteria to each of the 13
                            governance options it developed. 41 In establishing the MHS review, the
from Internal               Deputy Secretary of Defense prescribed that the review should assess
Stakeholders, but Did Not   potential governance options based on their fulfillment of the following
Provide Support for the     criteria:
Quantitative Elements
Included in Its Criteria    •     Provision of high-quality, integrated medical care for servicemembers
                                  and eligible beneficiaries;

                            •     Maintenance of a trained and ready deployable medical force to
                                  support combatant commanders;


                            39
                                 GAO-11-318SP.
                            40
                                 GAO-12-224.
                            41
                               Qualitative methods include collecting data through interviews, focus groups, document
                            or literature reviews, and observation, and analyzing data by discerning, examining,
                            comparing, and contrasting meaningful patterns or themes in qualitative data. Quantitative
                            methods typically involve collecting quantifiable data or other information, and may include
                            the use of probability sampling using various forms of statistical analysis to generalize
                            results. Evaluations using mixed methods employ a combination of qualitative and
                            quantitative data collection and analysis techniques.




                            Page 28                                                    GAO-12-911 Defense Health Care
•    Achievement of significant cost-savings through, for example,
     elimination of redundancies, increased interoperability, and other
     means of promoting cost-efficient delivery of care.

     The Deputy Secretary of Defense noted that the Task Force members
     could consider additional criteria in their review. As such, the Task
     Force members collectively decided to split the criteria provided by
     the Deputy Secretary of Defense into separate criteria and add two
     new criteria, for a total of seven criteria used to assess the MHS
     governance options (see Figure 6). The Task Force members also
     collectively defined each of the criteria and added a weight to each
     based on their expert opinion of the relative importance of the criteria.


Figure 6: Criteria Used to Assess MHS Governance Options




The definitions of the seven criteria used by DOD—while mostly
qualitative—included elements for certain criteria that called for
quantitative data. For example,

•    DOD defined the Ease of Implementation criterion as “The alternative
     should be implementable taking into account Title 10 equities, 42 short-
     term costs and long-term savings, and decisions required inside and



42
  DOD’s Task Force report did not define Title 10 equities. Title 10 of the United States
Code contains the organic law governing the Armed Forces of the United States and
providing for the organization of the Department of Defense, including the military
departments and the Reserve Components.




Page 29                                                    GAO-12-911 Defense Health Care
     outside of the DOD.”

•    DOD defined the Achieve Significant Cost Savings through Reduction
     in Duplication and Variation criterion as “The alternative should result
     in a reduction of the system operating costs.”

As we have previously reported, the quality of assessments can be
strengthened by using a mixed approach that includes both qualitative
and quantitative information to remove concerns about bias in one data
source. 43 DOD’s review obtained a great deal of qualitative information
from stakeholders and internal experts and used this information to
support its assessment of the strengths and weaknesses of the
governance options, but it did not balance this assessment with
quantitative data. Specifically DOD’s assessments of the strengths and
weaknesses did not provide data to support the quantitative elements
specified in its own criteria as indicated in the following two examples.

•    DOD did not attempt to estimate the range of either short- or long-
     term costs or savings data associated with the governance structures
     in the 14 instances where Ease of Implementation was listed either as
     a strength or a weakness. Instead, the DOD report cited qualitative
     information such as “this action would represent a significant
     departure in governance for all existing organizations” or “this will
     entail a large scale reorganization to include re-mapping of service
     medical personnel to operational platforms and there is no known
     precedent or example where this approach has been tested in other
     military medical organizations worldwide” as support for the
     assessment of this criterion. As one leading industry official told us,
     statements about how hard it would be to change and that the change
     would be too disruptive to actually implement is not sufficient evidence
     for avoiding necessary change.

•    DOD did not provide cost data as support for the 11 instances where
     Achieve Significant Cost Savings through Reduction in Duplication
     and Variation was listed as a strength or a weakness. During the Task
     Force meetings, members expressed concern that no business case
     was presented for the governance options, and that the support
     presented for the assessment of strengths and weaknesses were



43
  GAO, Designing Evaluations: 2012 Revision, GAO-12-208G (Washington, D.C.: Jan.
12, 2012).




Page 30                                              GAO-12-911 Defense Health Care
      “descriptive statements.” According to the meeting minutes, it was
      understood by the Task Force that “deeper analytical work will be
      required following the submission of the report.”

Furthermore, DOD’s report listed the Medical Readiness criterion as a
weakness for five options but did not provide supporting examples or
quantitative data for this assessment. DOD defined Medical Readiness as
“The alternative should maintain or enhance the ability to provide
medically ready warfighters.” As support for the assessments where this
criterion was listed as a weakness, DOD stated that coordination between
Service Chiefs and Military Department Secretaries would be required
under governance options where medical personnel were still “owned” by
their service components. For governance options that included a split
between unified medical command and military-led defense health
agency, DOD stated that these structures would effectively split the
readiness sustainment between the higher command and the services,
thereby making the development and sustainment of the medical
readiness forces more complex. However, DOD did not specifically
identify the types of complexities or provide supporting examples in which
such organizational issues have resulted in a negative impact on medical
readiness. In July 2010, we reported that the services’ collaborative
planning efforts regarding requirements determination for medical
personnel working in fixed military treatment facilities have been limited,
and recommended that DOD develop and implement cross-service
medical manpower standards for common medical capabilities. 44 DOD did
not address how the potential governance structures they presented
would affect such issues. Similarly, DOD did not discuss or provide
support for how the governance structures would impact the other MHS
priorities—population health, experience of care, and per capita cost—
even though quantitative data that measure the performance of these
priorities for the current governance structure are available. 45

In addition, DOD’s assessment of the strengths and weaknesses was
often unclear. Specifically, 10 of the 13 assessments of governance
options listed at least one criterion as support for both a strength and a



44
   GAO, Military Personnel: Enhanced Collaboration and Process Improvements Needed
for Determining Military Treatment Facility Medical Personnel Requirements, GAO-10-696
(Washington, D.C.: July 29, 2010).
45
     Department of Defense, 2012 MHS Stakeholder’s Report.




Page 31                                                 GAO-12-911 Defense Health Care
                             weakness, without coming to a conclusion as to whether the criterion was
                             a strength or a weakness on balance. For example, in its assessment of
                             its preferred governance option (Defense Health Agency with Service
                             Medical Treatment Facilities), DOD listed the Enhance Interoperability
                             criterion as both a strength and a weakness for the option without coming
                             to a final conclusion as to the net effect of this assessment. Task Force
                             members we met with told us that for options where the same criterion
                             was listed as both a strength and a weakness, each Task Force member
                             would make their own judgment as to which was a more important
                             characteristic and vote accordingly – taking into account the perspective
                             of their organization or service and the weighting of the criteria. This
                             approach to assessing the strengths and weaknesses of the options
                             illustrates the subjective nature of DOD’s analysis, and highlights an area
                             where additional support, specifically quantitative data, would have
                             improved the clarity and robustness of DOD’s conclusions about the
                             strengths and weaknesses of the governance options.


DOD’s Assessment Did Not     DOD weighted its criteria according to relative importance but DOD’s
Provide Supporting           assessment of strengths and weaknesses did not mention two of the
Information for Two of the   three criteria weighted as most important. As noted earlier, DOD assigned
                             various weights to the seven criteria used to assess the governance
Criteria It Identified as    options as shown in figure 6. The DOD report stated that the weighting
Most Important               system was developed to reflect the relative importance of the criteria.
                             However, two of the top three criteria with the greatest assigned weight—
                             Trained and Ready Medical Force and Quality Beneficiary Care—were
                             not mentioned in DOD’s assessment of the strengths and weaknesses.
                             See figure 7.




                             Page 32                                         GAO-12-911 Defense Health Care
Figure 7: Frequency that the Criteria Were Listed as a Strength or Weakness for Potential Governance Structures




                                         DOD officials told us that these two criteria were not discussed in the
                                         report because the Task Force members agreed that each governance
                                         option presented in the report would meet both of these criteria. However,
                                         DOD did not provide an explanation or justification as to how each
                                         governance option would satisfy the two criteria in question. The officials
                                         added that there was a general understanding among the Task Force
                                         members that no option that adversely affected these two criteria would
                                         be recommended. However, five of DOD’s options presented medical
                                         readiness of the active duty force, a related and similarly important
                                         concept, as a weakness. Because DOD’s report does not discuss the
                                         criteria they identified as the most important for their assessment of the
                                         strengths and weaknesses—including providing support for why each


                                         Page 33                                              GAO-12-911 Defense Health Care
                      option equally satisfied the Trained and Ready Medical Force and Quality
                      Beneficiary Care criteria—DOD and Congress lack assurance that these
                      criteria were sufficiently considered in DOD’s assessment. As a result,
                      decision makers may not have well-supported, data-driven information
                      about the strengths and weaknesses of the potential MHS governance
                      options.


                      Transforming the governance structure of the MHS represents a potential
Conclusions           opportunity to implement more efficient ways of doing business while
                      maintaining a ready and trained medical force as well as continuing to
                      meet the needs of military personnel, retirees, and their dependents.
                      Reliable and comprehensive information, including implementation and
                      other associated costs, is needed to provide a data-driven rationale for
                      why DOD may be undertaking consolidation initiatives, and a clearly
                      presented business-case or cost-benefit analysis can justify the benefits
                      of such action. DOD has repeatedly studied options to transform its
                      governance structure, but has relied on implementing “interim steps” or
                      incremental changes toward an unknown final governance structure,
                      often without the benefit of a clear understanding of the costs and
                      benefits of its actions. DOD risks repeating this pattern without full
                      knowledge of the costs, strengths, and weaknesses of each of the
                      options. As DOD moves forward with its plans to transform its governance
                      structure, it is imperative that officials benefit from full and complete
                      information to be assured that they choose the best alternative and that
                      their efforts yield necessary improvements and achieve maximum
                      efficiencies.


                      To provide decision makers with more complete information on the total
Recommendations for   cost impact of the various governance structures to help determine the
Executive Action      best way forward, we recommend that the Secretary of Defense direct the
                      Assistant Secretary of Defense (Health Affairs) to:

                      •   Develop a comprehensive cost analysis for the MHS governance
                          structures including estimates of implementation costs and cost
                          savings in additional areas such as health care operations and
                          infrastructure changes as well as an improved estimate of personnel
                          savings,

                      •   Develop a business case analysis and strategy for the implementation
                          of its shared services concept,




                      Page 34                                        GAO-12-911 Defense Health Care
                     •   Improve its evaluation of the potential governance structures’
                         strengths and weaknesses by including quantitative data when
                         available, and a specific assessment of the degree to which the
                         options meet the criteria Trained and Ready Medical Force and
                         Quality Beneficiary Care.

                     In written comments provided in response to our draft report, DOD
Agency Comments      concurred with one of our recommendations and did not concur with the
and Our Evaluation   remaining two recommendations. DOD’s written comments are reprinted
                     in appendix III of this report.

                     In concurring with our recommendation that DOD develop a business
                     case analysis and a strategy for the implementation of its shared services
                     concept, DOD agreed, but on the premise that it can and should occur in
                     the context of its ongoing implementation planning effort for the creation
                     of a defense health agency. DOD reiterated that all of the potential
                     governance options under consideration include a shared services
                     concept and noted that as part of its implementation planning, it will
                     ascertain which shared services, functions, and activities will be
                     consolidated. Additionally, DOD stated it will produce a detailed
                     implementation timeline for the transfer of each such service to the
                     defense health agency. We agree this effort to identify which services will
                     be consolidated and to develop a timeline for the migration of these
                     services is important. DOD states that shared services and common
                     business practices will realize savings, but we are concerned that DOD is
                     moving forward in implementing its shared services concept without
                     knowledge of implementation costs or an estimated return on its
                     investment. Further, with respect to DOD’s governance decisions on the
                     multi-service markets and the National Capital Region, DOD states that
                     our recommendations for additional analysis did not apply to these
                     reforms. We did not include these specific areas in our recommendation
                     because the potential governance options for the multi-service markets
                     and the National Capital Region were outside the scope of our mandated
                     review. As a result, we did not address the extent to which DOD’s reform
                     plans for the multi-service markets and the National Capital Region may
                     or may not require additional analysis. However, several senior DOD
                     officials noted during the course of our review that while they recognize
                     efficiencies could be gained in multi-service markets, they expressed
                     reservations concerning the details of DOD’s plans for reforming such
                     markets.




                     Page 35                                         GAO-12-911 Defense Health Care
In its non-concurrence with our recommendation that DOD develop a
comprehensive cost analysis for the MHS governance structures,
including (1) estimates of implementation costs, (2) cost savings in
additional areas such as health care operations and infrastructure
changes, and (3) and an improved estimate of personnel savings, DOD
noted that it recognizes that a more detailed and comprehensive cost
analysis of governance options could be undertaken. However, DOD
states that further cost analysis will not help to materially distinguish
among the options. We disagree with DOD and believe that more
comprehensive cost analysis will help to distinguish the differences
among the costs and benefits of the options. First, DOD did not estimate
implementation costs for any of its 13 governance options. As we
reported, significant implementation costs are a key element of a
comprehensive cost analysis, as illustrated in the case of the Base
Realignment and Closure (BRAC) process, in which DOD’s one-time
implementation costs increased 53 percent over the BRAC Commission’s
original estimate. Second, we continue to believe that further analysis of
cost savings areas beyond personnel cost savings, such as health care
operations or reduced infrastructure, could help DOD to materially
distinguish among the governance options. Third, DOD’s estimate of
personnel cost savings used several potentially flawed assumptions, and
as a result, we determined DOD’s estimate to be unreliable. In its
decision to move forward with implementation of the defense health
agency, DOD not only lacks any estimate of implementation costs and
cost savings in areas such as healthcare operations and reduced
infrastructure, but also reliable estimates of personnel cost savings. DOD
also stated in its non-concurrence that its decision to affect incremental
change through the implementation of a defense health agency enjoys
the consensus of the most senior military leaders. However, the decision
for this option is based on incomplete and potentially flawed data. Absent
such information, we continue to believe that DOD lacks a sound basis
upon which to make its decision about the future of MHS governance.

In its non-concurrence with our recommendation that DOD include
quantitative data as available in its assessment of the strengths and
weaknesses of the potential overall governance structures and conduct a
specific assessment of the degree to which the options meet the criteria
for Trained and Ready Medical Force and Quality Beneficiary Care, DOD
stated that the work of the MHS governance task force provided DOD
senior leaders with sufficient information to make decisions among near-
term medical governance reform options based on a variety of criteria,
many of which are inherently qualitative in nature and would not
significantly benefit from the sort of quantitative data we recommended


Page 36                                         GAO-12-911 Defense Health Care
that DOD include. However, DOD’s own criteria for the assessment of the
potential governance structures called for the inclusion of quantitative
information, as we reported. Further, DOD’s response to our draft report
did not specifically address the portion of our recommendation that a
specific assessment of the degree to which the potential governance
options meet the criteria Trained and Ready Medical Force and Quality
Beneficiary Care—two of the three most important criteria according to
DOD task force members. Without inclusion of these criteria coupled with
the lack of quantitative data, it remains unclear how DOD senior leaders
have sufficient information to make decisions regarding near-and long-
term medical governance reform options. Therefore, we believe our
recommendation that DOD improve its evaluation of the potential
governance structures’ strengths and weaknesses by including
quantitative data in its assessment and to determine the impact on a
trained and ready medical force and the quality of beneficiary care
remains valid.

In its comments, DOD noted that it is committed to the MHS governance
changes agreed to by the Department leadership in 2012 that are
presented in its report in response to Section 716 of the National Defense
Authorization Act for Fiscal Year 2012. As we noted, Section 716 required
DOD to submit a report to the congressional defense committees to
include, among other things, a description of the alternative MHS
governance options developed and considered by the Task Force; an
analysis of the strengths and weaknesses of each option; and an
estimate of the cost savings, if any, to be achieved by each option. DOD
stated that to undertake the additional evaluation we recommended would
not only be time-consuming but also inherently speculative and imprecise,
and that additional analysis would not alter its conclusion about which
governance reforms to pursue in the near term. We are not suggesting
that DOD not reap the benefits of certain desirable, near-term reforms,
such as the development of a business-case analysis for its shared
services followed by its implementation, and we recognize that
implementing these near-term reforms can provide some insight into the
potential benefits of further transformation efforts. As we noted in our
report, under the current governance structure, the Assistant Secretary of
Defense (Health Affairs) has the broad authority that could allow for the
implementation of shared support services across MHS, and DOD has
had an opportunity to develop a supporting business case analysis since
this concept was first proposed in 2006. However, given the complex and
costly nature of MHS, we continue to believe that changes to its overall
governance should be well thought out and analyzed to ensure that there
are significant, measurable benefits before being implemented. In


Page 37                                        GAO-12-911 Defense Health Care
addition, the need to improve the evaluation of potential governance
options by considering critical information such as the cost of DOD’s
reforms, their possible cost savings, and a thorough discussion of the
options’ strengths and weaknesses would benefit DOD’s decision-making
process. DOD has repeatedly studied options to transform its governance
structure, but has relied on implementing “interim steps” or incremental
changes toward an unknown final governance structure, often without the
benefit of a clear understanding of the costs and benefits of its actions.
Prior attempts to proceed with MHS reorganization without the benefit of
such information demonstrate the effects of such an approach. In 2007,
DOD did not conduct a comprehensive cost-benefit analysis, including an
analysis of benefits, costs, and risks, for proceeding with its preferred
medical governance concept at that time, which consisted of seven
different incremental governance initiatives. At the time, DOD concurred
with our recommendation that they develop such an analysis, but we
reported in 2011 that it had not done so. We reiterate that DOD risks
repeating this pattern if it does not develop full knowledge of the costs,
strengths, and weaknesses of each of the options under consideration.

DOD noted that it is currently planning for the implementation of its
governance reforms, and that it expects the defense health agency to
reach an initial operating capability by 2013, with full operating capability
within 2 years. We will continue to monitor DOD’s efforts to reform MHS
governance.


We are sending copies of this report to interested congressional
committees, the Secretary of Defense, the Deputy Secretary of Defense,
the Under Secretary of Defense for Personnel and Readiness, the
Assistant Secretary of Defense (Health Affairs), the Surgeon General of
the Air Force, the Surgeon General of the Army, and the Surgeon
General of the Navy. In addition, the report is available at no charge on
the GAO website at http://www.gao.gov.




Page 38                                           GAO-12-911 Defense Health Care
If you or your staff have any questions regarding this report, please
contact me at (202) 512-3604 or farrellb@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in appendix IV.




Brenda S. Farrell
Director
Defense Capabilities and Management




Page 39                                         GAO-12-911 Defense Health Care
List of Committees

The Honorable Carl Levin
Chairman
The Honorable John McCain
Ranking Member
Committee on Armed Services
United States Senate

The Honorable Daniel K. Inouye
Chairman
The Honorable Thad Cochran
Ranking Member
Subcommittee on Defense
Committee on Appropriations
United States Senate

The Honorable Howard P. “Buck” McKeon
Chairman
The Honorable Adam Smith
Ranking Member
Committee on Armed Services
House of Representatives

The Honorable C.W. Bill Young
Chairman
The Honorable Norman D. Dicks
Ranking Member
Subcommittee on Defense
Committee on Appropriations
House of Representatives




Page 40                                 GAO-12-911 Defense Health Care
Appendix I: Scope and Methodology
             Appendix I: Scope and Methodology




             To determine how the Department of Defense’s (DOD) preferred
             governance option, and the other options presented in its report, changes
             the current structure of the MHS, we first obtained documentation
             describing key changes in the Military Health System (MHS) governance
             structure since 1991 by reviewing relevant DOD directives, legislation,
             and interviewing knowledgeable DOD officials. Using this as the basis for
             what constitutes the current MHS governance system, we then reviewed
             DOD’s description of each of the proposed changes to the current
             governance options in the Task Force report. Upon review of all of the
             historical as well as proposed changes to the MHS governance structure,
             we identified three common governance elements among them all: the
             overall control of policy-making authority, budgetary authority, and control
             of medical personnel. As a guide for developing our comparison of the
             changes, we used these elements to describe the differences among the
             various governance options and key changes that have shaped the
             current structure. We defined these three governance elements to
             encompass the following activities:

             •     Overall Control of Policy-Making Authority: Who controls the overall
                   MHS? Who heads its various entities? Who reports to the Secretary of
                   Defense? What is the command and control structure? Who
                   establishes MHS policy for the Office of the Secretary of Defense, the
                   Services, and joint entities? What are the roles of senior leaders?

             •     Budgetary Authority: Who controls the Defense Health Program
                   appropriation?

             •     Control of Personnel: Who manages and supervises the Military
                   Treatment Facilities and multi-service medical markets? Who controls
                   the MHS mission and administrative support personnel among the
                   Office of the Secretary of Defense, the Military Departments, and/or
                   joint entities?

             To review DOD’s shared services concept, we reviewed the information
             presented in DOD’s report and interviewed DOD officials concerning their
             analysis of this concept. We compared this information to our prior work
             on business case analyses in the context of management consolidations, 1
             and leveraged our prior work on efforts by DOD and other federal



             1
                 GAO-12-542.




             Page 41                                          GAO-12-911 Defense Health Care
Appendix I: Scope and Methodology




agencies to establish shared services to provide context for DOD’s
current efforts. 2

To determine the extent to which DOD has developed a cost analysis of
its potential MHS governance options, we reviewed DOD’s cost
assessments for its governance options using key principles we derived
from cost estimating and budgeting guidance. Specifically, we reviewed
numerous federal guidance documents related to cost estimating,
accounting standards, economic analysis, and budgeting and identified
key principles that we believe can be applied to the evaluation of cost
savings estimates. The guidance documents we reviewed include GAO
Cost Estimating and Assessment Guide, GAO-09-3SP; Office of
Management and Budget Circular No. A-11, Preparation, Submission and
Execution of the Budget (Aug. 2011, superseded by an August 2012
issuance); Federal Accounting Standards Advisory Board, Statement of
Federal Financial Accounting Standards 4 (June 2011); Department of
Defense Instruction 7041.3, Economic Analysis for Decisionmaking (Nov.
7, 1995); and Department of Defense Financial Management Regulation
7000.14-R, Volume 4, Chapter 22, Cost Finding (May 2010). Although
each of these documents may not apply to these circumstances as a
legal matter, we believe that they collectively contain broad themes that
can be applied to evaluating cost analyses. To apply these key principles,
we interviewed Task Force members concerning the extent to which they
attempted to estimate implementation costs and reviewed the cost
savings presented in DOD’s report. We identified broad cost categories
that should be considered in the course of implementing DOD’s
governance transformation by leveraging prior GAO work on the
implementation costs of major transformations and consolidations, such
as the Base Realignment and Closure (BRAC) process, and CNA’s
report, Cost Implications of a Unified Medical Command. 3 In reviewing
DOD’s cost savings estimate, we interviewed officials concerning their
estimating methods and reviewed supporting documentation, noting
where we identified shortcomings in the Task Force’s approach. We were
unable to rely on DOD’s cost savings estimates because the estimates
and their supporting data were insufficient in the key data elements
needed to completely and accurately develop them as discussed in the
findings section of this report.


2
    GAO-07-536 and GAO-12-224.
3
    GAO-12-542.




Page 42                                        GAO-12-911 Defense Health Care
Appendix I: Scope and Methodology




To determine the extent to which DOD’s assessment of the strengths and
weaknesses of its potential governance options is well-supported and
data-driven, we obtained and analyzed Task Force documents including
meeting minutes, briefing slides, and voting templates. We then used this
analysis to determine the criteria and process used to formulate the
strengths and weaknesses of the options. We then assembled a list of the
78 strengths and weaknesses cited in the task force report and used a
semi-structured interview process to collect information from Task Force
officials regarding the process and inputs used to formulate each
assessment. We then conducted a content analysis of the information
provided by the officials to identify and categorize the inputs that the
officials cited as contributing to the assessments of strengths and
weaknesses. The categorization of the information was conducted by one
analyst and confirmed by a second analyst to ensure the analysis was
adequately supported by the evidence. In addition, we interviewed
officials from one multi-service market and a health administration expert
to obtain their opinions on the process used by DOD to formulate the
strengths and weaknesses.

For each of our objectives, we limited our review to the potential overall
governance structures that the Task Force presented in its report. We did
not specifically review the proposed changes to DOD’s multi-service
medical markets or to the governance structure in place within the
National Capital Region as presented in the Task Force report because
we determined that these proposed changes were outside the scope of
our mandate. We conducted this performance audit from March 2012
through September 2012 in accordance with generally accepted
government auditing standards. Those standards require that we plan
and perform the audit to obtain sufficient, appropriate evidence to provide
a reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.




Page 43                                         GAO-12-911 Defense Health Care
Appendix II: Detailed Description of the
                          Appendix II: Detailed Description of the
                          Potential Governance Structures and DOD’s
                          Assessment of Their Strengths and

Potential Governance Structures and DOD’s
                          Weaknesses



Assessment of Their Strengths and Weaknesses
                          DOD’s task force report provided the following detailed description, cost
                          savings estimates, 1 and strengths and weaknesses of the governance
                          structures 2 it identified as potential options for its Military Health System
                          (MHS). As we noted earlier in our report, we found DOD’s cost savings
                          estimates to be unreliable because the estimates and their supporting
                          data were insufficient in the key data elements needed to completely and
                          accurately develop them. As a result, using DOD’s data as presented
                          below may lead to an incorrect or unintentional result.



Defense Health
Agency Governance
Structures
Defense Health Agency     DOD’s preferred option would create a new defense health agency that
with Military Treatment   would assume the responsibilities of the TRICARE Management Activity
Facilities under the      and additional possible areas of savings known as shared services. The
                          new agency would be a combat support agency headed by a 3-star
Services                  general or flag officer who would report to the Assistant Secretary of
                          Defense (Health Affairs), but with oversight from the Chairman of the
                          Joint Chiefs of Staff. The services would maintain their surgeons general,
                          service support commands, and intermediate headquarters.




                          1
                              We determined DOD’s cost savings estimates to be unreliable.
                          2
                            These structures are in addition to the current MHS structure, which the Task Force
                          included in the 13 options presented in the report.




                          Page 44                                                   GAO-12-911 Defense Health Care
                                            Appendix II: Detailed Description of the
                                            Potential Governance Structures and DOD’s
                                            Assessment of Their Strengths and
                                            Weaknesses




                                            DOD’s Estimate of Projected Net Savings: $46.5 million per year.

DOD’s Assessment of Strengths                                          DOD’s Assessment of Weaknesses
•   Lines of Authority: The services control the hospital and          •   Enhance Interoperability: Eliminates the Joint Hospitals in
    deployed health care; eliminates the Assistant Secretary of            the National Capital Region as well as San Antonio.
    Defense role as the Director of the TRICARE Management             •   Ease of Implementation: This option would require the
    Activity.                                                              Joint Task Force National Capital Region Medical to
•   Enhance Interoperability: The defense health agency would be           transition to a different structure. The services’ cultures
    focused on the shared and consolidated services.                       could limit the implementation of common services and
•   Ease of Implementation: This would require minimal change to           processes.
    the current service organizational structure.




Defense Health Agency                       Similar to the previous option, this structure would create a defense
with Military Treatment                     health agency combat support agency led by a 3-star general or flag
Facilities Placed under the                 officer, but would place Military Treatment Facilities under the authority,
                                            direction, and control of the agency. Military personnel not assigned to a
Agency                                      deployable unit would be under the direction of the defense health
                                            agency, but the services would continue to own their personnel, and all
                                            civilian personnel would be under the direction of the agency.

                                            DOD’s Estimate of Projected Net Savings: $87.4 million per year.

DOD’s Assessment of Strengths                                          DOD’s Assessment of Weaknesses
•   Dispute Resolution/Lines of Authority/Accountability:              •   Dispute Resolution/Lines of Authority/Accountability: This
    Management of all medical treatment facilities under one               model may elevate management disputes to the highest
    authority (Director, Defense Health Agency); the Defense               levels of the DOD, as local line command disputes with the
    Health Agency Director would report directly to the Assistant          defense health agency command structure may need to be
    Secretary of Defense (Health Affairs).                                 adjudicated at the level of the Secretary of the Military
                                                                           Department /Assistant Secretary of Defense (Health
•   Achieve Significant Cost Savings Through Reduction in                  Affairs) level.
    Duplication and Variation: The defense health agency would be      •   Medical Readiness: Concerns were expressed that an
    focused on the most common theme emphasized by the Task                organization this large with this many authorities could
    Force – an organizational model that would accelerate                  jeopardize services priorities. A comprehensive defense
    implementation of shared services models that identify and             health agency could reduce command and leadership
    proliferate best practices and consider entirely new approaches        development opportunities.
    to delivering shared activities. Further, placement of medical     •   Ease of Implementation: Moving all medical treatment
    treatment facilities under the defense health agency would allow       facilities to the defense health agency would be a major
    for even more rapid implementation of unified clinical and             reorganization.
    business systems, which could create significant savings.
                                                                       •   Other: Could mix the defense health agency mission
                                                                           between support of MHS-wide functions and direct
•   Other: Would align management of purchased care (TRICARE)              operation of hospitals and clinics. The Military
    and direct care (Medical Treatment Facilities) under one entity,       Department’s representatives on the Task Force believed
    creating potential for greater coordination and cost-effective         that operation of the direct care system is a Military
    distribution of resources between the two sources of care.             Department responsibility.




                                            Page 45                                                    GAO-12-911 Defense Health Care
                                             Appendix II: Detailed Description of the
                                             Potential Governance Structures and DOD’s
                                             Assessment of Their Strengths and
                                             Weaknesses




                                             Weaknesses of a DHA with MTFs under the Agency


Defense Health Agency –                      This option would create a Defense Health Agency to exercise authority,
Geographic Model                             direction, and control over the Military Treatment Facilities. However,
                                             service intermediate headquarters would be replaced by a single defense
                                             health agency-run organization.

                                             DOD’s Estimate of Projected Net Savings: $21.4 million per year.

DOD’s Assessment of Strengths                                            DOD’s Assessment of Weaknesses
•   Lines of Authority: This organizational construct would have         •   Dispute Resolution: Key issues would be elevated quickly
    clear lines of authority and there would be central control of the       to the highest levels.
    Military Treatment Facilities.                                       •   Ease of Implementation: This option would be more of a
•   Enhance Interoperability: This option would allow for single             “civilianized” model which may be difficult to implement in
    processes for key functions.                                             the current military structure. It may also reduce command
                                                                             leadership opportunities and professional growth.




Unified Medical
Command
Governance
Structures
Unified Medical Command                      A unified medical command with service components option would create
with Service Components                      a tenth combatant command led by a 4-star general or flag officer, with
                                             forces supplied by service components. Service intermediate
                                             headquarters would manage the Military Treatment Facilities, but
                                             personnel not assigned to deployable units would be assigned to the
                                             unified medical command. A Joint Health Support Command would
                                             manage the TRICARE health plan and shared services.




                                             Page 46                                                    GAO-12-911 Defense Health Care
                                            Appendix II: Detailed Description of the
                                            Potential Governance Structures and DOD’s
                                            Assessment of Their Strengths and
                                            Weaknesses




                                            DOD’s Estimate of Projected Net Cost: $203.6 million per year.

DOD’s Assessment of Strengths                                           DOD’s Assessment of Weaknesses
•   Dispute Resolution/Lines of Authority/Accountability: Clear lines   •   Dispute Resolution/Lines of Authority/Accountability: The
    of authority would be established.                                      current structure of civilian authority over components of
•   Achieve Significant Cost Savings Through Reduction in                   the MHS (the Assistant Secretary of Defense (Health
    Duplication and Variation: There would be central control of            Affairs)) and Military Department Secretaries) would not be
    common business and clinical processes, and implementation              maintained; the first civilian official in the authority chain
    would be achieved more readily with command and control                 would be the Secretary of Defense.
    throughout the medical structure to ensure compliance.              •   Achieve Significant Cost Savings Through Reduction in
•   Ease of Implementation: Joint Task Force National Capital               Duplication and Variation: In any unified medical command
    Region Medical, if retained in its current form, could be               structure that maintains service Components (the common
    addressed as a region directly reporting to the Commander,              model for all unified commands) the overall management
    U.S. Medical Command.                                                   headquarters overhead would increase above “As Is” and
                                                                            all other organizational models.
                                                                        •   Ease of Implementation: This action would represent a
                                                                            significant departure in governance for all existing
                                                                            organizations (Assistant Secretary of Defense (Health
                                                                            Affairs), TRICARE Management Activity, Military
                                                                            Department Secretaries, Military Service Chiefs, Service
                                                                            Medical Departments). For the Air Force, this includes
                                                                            creating a medical component command for operation of
                                                                            Air Force medical treatment facilities; the Navy would need
                                                                            to redesign how garrison billets are mapped to operational
                                                                            requirements.




Unified Medical Command,                    This structure would create a tenth combatant command for medical care.
Geographic Model                            However, the unified medical command commander would exercise
                                            control over personnel and the Military Treatment Facilities. Service
                                            intermediate headquarters would be replaced by a single organization.

                                            DOD’s Estimate of Projected Net Cost: $152.3 million per year.




                                            Page 47                                                      GAO-12-911 Defense Health Care
                                           Appendix II: Detailed Description of the
                                           Potential Governance Structures and DOD’s
                                           Assessment of Their Strengths and
                                           Weaknesses




DOD’s Assessment of Strengths                                          DOD’s Assessment of Weaknesses
•   Dispute Resolutions and Lines of Authority: This organizational    •   Lines of Authority: This would be a major change for the
    structure would have clear lines of authority and there would be       Service Surgeons General.
    central control of the Military Treatment Facilities. The shared   •   Enhance Interoperability: Some required service assets
    services (i.e. education and training, research and development,       would not be under service control — sourcing would be
    health information technology, logistics) would be centrally           from the unified medical command.
    managed. The TRICARE Regional Offices would be aligned with
    the Military Treatment Facilities in the same chain of command.    •   Ease of Implementation: This would be a massive change
                                                                           for the way the DOD does business. Hospital based and
•   Enhance Interoperability: This option would focus the                  wartime medical forces would be split. An alternative is to
    development of common business processes.                              embed deployable wartime forces in a Joint Table of
•   Ease of Implementation: The Joint Table of Distributions would         Distribution in the unified medical command.
    eliminate any multi-service market issues because the unified      •   Achieve Significant Cost Savings through Reduction in
    medical command would control the multi-service markets.               Duplication and Variation: The Command may be focused
•   Achieve Significant Cost Savings Through Reduction in                  on effectiveness over costs.
    Duplication and Variation: Reduction in overhead personnel
    would be relative to the current MHS structure. Services would
    focus on deployable forces with the unified medical command as
    the platform for medical professional force development and
    benefit delivery.


                                           Unified Medical Command, HR 1540 3

                                           This option would create a tenth combatant command for medical care
                                           with forces supplied by service components. Subordinate service
                                           commands would manage the Military Treatment Facilities, but within the
                                           framework of a Healthcare Command led by a 3-star general or flag
                                           officer to manage the service components.

                                           DOD’s Estimate of Projected Net Cost: $238.8 million per year.




                                           3
                                            H.R. 1540, which became the National Defense Authorization Act for Fiscal Year 2012,
                                           Pub. L. No. 112-81 (2011), when initially passed by the House, contained a provision (sec.
                                           711) that would have required the establishment of a unified medical command. That
                                           provision was not ultimately enacted, and was replaced by section 716 during conference.




                                           Page 48                                                    GAO-12-911 Defense Health Care
                                             Appendix II: Detailed Description of the
                                             Potential Governance Structures and DOD’s
                                             Assessment of Their Strengths and
                                             Weaknesses




DOD’s Assessment of Strengths                                            DOD’s Assessment of Weaknesses
•   • Dispute Resolution/Lines of Authority/Accountability: Clear        •   • Achieve Significant Cost Savings Through Reduction in
    lines of authority would be established as well as central               Duplication and Variation: The Command would likely be
    management of shared services (i.e. education and training,              focused more on effectiveness over costs.
    research and development, health information technology,             •   • Dispute Resolution/Lines of Authority/Accountability:
    logistics). Military Treatment Facilities would be centrally             Some required service assets would not be under service
    controlled.                                                              control. There would be civilian oversight for budget
•   • Enhance Interoperability: Allows for Joint Task Force National         located at the Secretary of Defense level which would
    Capital Region Medical to be easily inserted into this structure         bypass the Office of the Secretary of Defense Principal
    as a regional or sub-regional command. Common business                   Staff Assistant.
    processes would be implemented across the Military Treatment         •   • Enhance Interoperability: Hospital based and unit based
    Facilities.                                                              medical forces would be split.
•   • Ease of Implementation: The service component execution            •   • Ease of Implementation: This would require all three
    would minimize organizational change.                                    services to significantly change, with the biggest impact on
                                                                             the Air Force.
                                                                         •   • Dual-hatted surgeons general could face perception
                                                                             issues from home service and the unified medical
                                                                             command.




Single Service
Governance
Structures

Single Service with Service                  A single military service Secretary would be assigned all headquarters
Components                                   management functions, such as management of the TRICARE health
                                             plan and shared services. The designated service also would control a
                                             Defense Healthcare System agency that would include the service
                                             component commands, which in turn would command the Military
                                             Treatment Facilities.

                                             DOD’s Estimate of Projected Net Savings: $94.4 million per year.

DOD’s Assessment of Strengths                                            DOD’s Assessment of Weaknesses
•   • Dispute Resolution/Lines of Authority/Accountability: Clear        •   • Dispute Resolution/Lines of Authority/Accountability: This
    lines of authority would be established as well as central control       option would create a need for coordination of issues
    of the Military Treatment Facilities and multi-service markets.          between the service Secretaries.
    Service readiness assets would be under service control.             •   • Enhance Interoperability: This would split the warrior and
•   • Achieve Significant Cost Savings Through Reduction in                  beneficiary care systems.
    Duplication and Variation: There would be single processes for
    key functions




                                             Page 49                                                     GAO-12-911 Defense Health Care
                                             Appendix II: Detailed Description of the
                                             Potential Governance Structures and DOD’s
                                             Assessment of Their Strengths and
                                             Weaknesses




Single Service, Geographic                   Under this structure, a single military service Secretary would be
Model                                        assigned all headquarters management functions, such as management
                                             of the TRICARE health plan and shared services. In addition, the
                                             designated service would command all of the Military Treatment Facilities,
                                             while all services would remain responsible for providing personnel.

                                             DOD’s Estimate of Projected Net Savings: $94.4 million per year

DOD’s Assessment of Strengths                                            DOD’s Assessment of Weaknesses
•   • Dispute Resolution/Lines of Authority/Accountability: Clear        •   • Medical Readiness: With medical personnel still “owned”
    lines of authority and chain of command from Secretary through           by their service components, a requirement for
    the Military Treatment Facilities commander would be                     coordination between Service Chiefs and Military
    established.                                                             Department Secretaries on readiness and personnel
•   • Achieve Significant Cost Savings Through Reduction in                  issues would remain.
    Duplication and Variation: With shared services, there would be      •   • Ease of Implementation: There is no known precedent or
    one set of business and clinical processes and implementation            example where this approach has been tested in other
    would be achieved more readily with command and control in a             military medical organizations worldwide. The Navy/US
    single service. It also could eliminate the issues that arise with       Marine Corps medical support model does not have the
    multi-service markets. This option would create the most                 mission for all of the DOD; however, it is representative of
    significant savings in headquarters overhead of any                      how a single service model could work. Additionally, this
    organizational option.                                                   option would entail a large scale reorganization to include
•                                                                            re-mapping of service medical personnel to operational
                                                                             platforms.
                                                                         •   • Dispute Resolution/Lines of Authority/Accountability:
                                                                             Issues would be adjudicated at a higher level (Military
                                                                             Department Secretary).




Hybrid Governance
Structures

Unified Medical Command                      This option would create a tenth combatant command led by a 4-star
with Service Components                      general or flag officer, with forces supplied by service components, and
and Defense Health                           service commands charged with management of the Military Treatment
                                             Facilities. However, shared services would be split, with the unified
Agency                                       medical command in charge of readiness-focused areas and a defense
                                             health agency charged with beneficiary health care and clinical quality.

                                             DOD’s Estimate of Projected Net Cost: $225.3 million per year.




                                             Page 50                                                     GAO-12-911 Defense Health Care
                                            Appendix II: Detailed Description of the
                                            Potential Governance Structures and DOD’s
                                            Assessment of Their Strengths and
                                            Weaknesses




DOD’s Assessment of Strengths                                            DOD’s Assessment of Weaknesses
•   • Dispute Resolution/Lines of Authority/Accountability: This         •   • Medical Readiness: Service readiness functions would
    option would align command and control forces under a military           be located in the unified medical command.
    chain of command. It would also align the Assistant Secretary of     •   • Dispute Resolution/Lines of Authority/Accountability: The
    Defense (Health Affairs) role to policy and oversight with               unified medical command commander would report
    execution delegated to the unified medical command                       directly to the Secretary of Defense. It could be difficult to
    commander and the defense health agency director.                        adjudicate disagreements between the unified medical
•   • Ease of Implementation: This option would maintain service             command and the defense health agency at the Deputy
    structures as component commands in the unified medical                  Secretary of Defense level.
    command. It would also support the Joint Task Force National         •   • Achieve Significant Cost Savings: The execution of the
    Capital Region Medical structure.                                        shared services and common processes would require
                                                                             unified medical command and defense health agency
                                                                             agreement.




Unified Medical Command                     Similar to the above, this option would pair a tenth combatant command
and Defense Health                          with a defense health agency with shared services divided between the
Agency, Geographic Model                    two organizations. However, the defense health agency through Regional
                                            Directors, not service components, would manage the Military Treatment
                                            Facilities.

                                            DOD’s Estimate of Projected Net Cost: $238.8 million per year.

DOD’s Assessment of Strengths                                            DOD’s Assessment of Weaknesses
•   • Dispute Resolution/Lines of Authority/Accountability: This         •   • Medical Readiness: Service readiness functions would
    option would align command and control forces under a military           be located in the unified medical command.
    chain of command. It would also align the role of the Assistant      •   • Dispute Resolution/Lines of Authority/Accountability: The
    Secretary of Defense (Health Affairs) to policy and oversight with       unified medical command commander would report
    execution delegated to the unified medical command                       directly to the Secretary of Defense. It could be difficult to
    commander and defense health agency director.                            adjudicate disagreements between the unified medical
•   • Achieve Significant Cost Savings: The execution of the shared          command and defense health agency at the Deputy
    services and common processes would require unified medical              Secretary of Defense level.
    command combatant command agreement.




Single Service with a                       Similar to the above two options, this option would pair a tenth combatant
Unified Medical Command                     command with another organization, a Defense Healthcare System in
                                            charge of all of the Military Treatment Facilities managed by one military
                                            service. Shared services also would be divided between the two
                                            organizations.

                                            DOD’s Estimate of Projected Net Cost: $238.8 million per year.




                                            Page 51                                                       GAO-12-911 Defense Health Care
                                              Appendix II: Detailed Description of the
                                              Potential Governance Structures and DOD’s
                                              Assessment of Their Strengths and
                                              Weaknesses




DOD’s Assessment of Strengths                                           DOD’s Assessment of Weaknesses
• Dispute Resolution/Lines of Authority/Accountability: This option     • Medical Readiness: This would split the warrior care and the
would establish clear lines of authority for administrative,            beneficiary care systems.
operational, and tactical control of forces with each being vested      • Dispute Resolution/Lines of Authority/Accountability: This option
in a different structure. It would also create central control of the   would create different responsible agents for administrative,
Military Treatment Facilities.                                          operational, and tactical control of forces.
• Ease of Implementation: In this option, the multi-service markets
are addressed and joint facilities would be maintained.
• Enhance Interoperability: This option would allow for single
processes for key functions.




Defense Health Agency                         The defense health agency would be led by a 3-star general or flag officer
Hybrid with Regional                          who would report directly to either a Service Secretary, the Assistant
Military Treatment                            Secretary of Defense (Health Affairs) or a combatant commander. The
                                              agency would control the TRICARE health plan. Additionally, a Medical
Facilities                                    Operations Support Command would be created to control the education
                                              and training, research and development, and public health. Finally, the
                                              individual military departments would continue to manage the Military
                                              Treatment Facilities, albeit through Service designated regional enhanced
                                              multi-service market offices instead of their current medical commands.

                                              DOD’s Estimate of Projected Cost/Saving: None presented.

DOD’s Assessment of Strengths                                      DOD’s Assessment of Weaknesses
•   None provided.                                                 •     None provided.




                                              Page 52                                                       GAO-12-911 Defense Health Care
Appendix III: Comments from the
              Appendix III: Comments from the Department
              of Defense



Department of Defense




              Page 53                                      GAO-12-911 Defense Health Care
Appendix III: Comments from the Department
of Defense




Page 54                                      GAO-12-911 Defense Health Care
Appendix III: Comments from the Department
of Defense




Page 55                                      GAO-12-911 Defense Health Care
Appendix III: Comments from the Department
of Defense




Page 56                                      GAO-12-911 Defense Health Care
Appendix III: Comments from the Department
of Defense




Page 57                                      GAO-12-911 Defense Health Care
Appendix IV: GAO Contact and Staff
                  Appendix IV: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Brenda S. Farrell, (202) 512-3604 or farrellb@gao.gov
GAO Contact
                  In addition to the contact named above, Lori Atkinson, Assistant Director;
Staff             Edward Anderson, Jr., Rebecca Beale, Grace Coleman, Foster Kerrison,
Acknowledgments   Charles Perdue, Carol Petersen, Terry Richardson, Adam Smith, and
                  Karen Nicole Willems made key contributions to this report.




                  Page 58                                         GAO-12-911 Defense Health Care
Related Products
              Related Products




              GAO, Defense Health Care: Applying Key Management Practices Should
              Help Achieve Efficiencies within the Military Health System, GAO-12-224
              (Washington, D.C.: April 12, 2012).

              GAO, 2012 Annual Report: Opportunities to Reduce Duplication, Overlap
              and Fragmentation, Achieve Savings, and Enhance Revenue,
              GAO-12-342SP (Washington, D.C.: Feb. 28, 2012).

              GAO, Follow-up on 2011, Status of Actions Taken to Reduce Duplication,
              Overlap, and Fragmentation, Save Tax Dollars, and Enhance Revenue,
              GAO-12-453SP (Washington, D.C.: Feb. 28, 2012).

              GAO, Opportunities to Reduce Potential Duplication in Government
              Programs, Save Tax Dollars, and Enhance Revenue, GAO-11-318SP
              (Washington, D.C.: Mar. 1, 2011).

              GAO, Defense Health Care: DOD Needs to Address the Expected
              Benefits, Costs, and Risks for Its Newly Approved Medical Command
              Structure, GAO-08-122 (Washington, D.C.: Oct. 12, 2007).




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              Page 59                                       GAO-12-911 Defense Health Care
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