oversight

Defense Health Care: Military Physicians' Views on Military Medicine

Published by the Government Accountability Office on 1990-03-22.

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

Marsh   1WO
                DEFENSE HEALTH
                CARE
                Military Physicians’
                Views on Military
                Medicine

                                       I
                                 111111
                                 140942




GAO/HRI)-90-l
Human Resources Division

B-238360

March 22, 1990

The Honorable Beverly B. Byron 1
Chairman, Subcommittee on Military
  Personnel and Compensation
Committee on Armed Services
House of Representatives

Dear Madam Chairman:

This report, prepared at your request, discusses the factors that most influence military
physicians to leave the, military and reviews the extent to which military physicians left the
service since 1986. In addition, the report illustrates how increasing physician compensation
and reducing the time physicians spend performing nonmedical tasks could diminish the
likelihood of attrition.

We are sending copies of this report to the Secretary of Defense, the service secretaries, and
interested congressional committees. We will also provide copies to the commanding officer
at each military treatment facility and to other interested parties on request.

This report was prepared under the direction of David P. Baine, Director, Federal Health
Care Delivery Issues, who can be reached on (202) 275-6207 if you have any questions about
the report, Other major contributors are listed in appendix IV.

Sincerely yours,


Lad    uuAGtLk\    -&      Lyy4h

Lawrence H. Thompson
Assistant Comptroller General
                                                                                             ,

      I

Executive Summq


                       The percentage of military physicians leaving the service increased in
                       recent years, from 13.7 in 1986 to 16.6 in 1988. This has caused concern
                       in the Congress and the military services because increases in the
                       number of active-duty physicians leaving the military may affect the
                       Department of Defense’s (DOD) ability to meet combat medical require-
                       ments in the event of war and its ability to provide services to benefi-
                       ciaries in peacetime.

                       To assist in structuring a long-term solution to the military physician
                       attrition problem, the Chairman, Subcommittee on Military Personnel
                       and Compensation, House Committee on Armed Services, asked GAO to
                       identify the reasons why military physicians are leaving the service in
                       increasing numbers. GAO sent a questionnaire to about 1,500 active-duty
                       physicians to assess

                   l the likelihood that physicians will leave the military, and
                   . the factors that most influence physicians’ decisions to leave the service.

  I
                       DOD'S $13 billion per year health care system employs over 13,000
Bdckground             active-duty physicians and serves about 9 million people.

                       Physician retention has concerned the Congress and DOD for some time.
                       To help reduce attrition, the Congress, in the 1989 National Defense
                       Authorization Act, established a bonus for many physicians who agreed
                       to remain in the service for 2 additional years.

                       As required by the 1989 National Defense Authorization Act, DOD sub-
                       mitted a report to the Congress that discussed issues affecting retention
                       of military physicians and proposed a pay program to address the com-
                       pensation gap with the civilian sector. DOD also submitted a follow-on
                       report that examined noncompensation issues.


                       Physicians’ intentions to leave the service over the next several years
Results in Brief       parallel DOD'S historical attrition rates. Almost one-half of the active-
                       duty physicians indicated at least a 70-percent probability of leaving the
                       service when they become eligible and about two-thirds voiced a 60-
                       percent chance of leaving.

                       Physicians reported dissatisfaction with many aspects of military
                       medicine. At least one-half were dissatisfied with their compensation,
                       the availability of administrative and health support personnel, hospital


                       Page 2                                  GAO/HRDBO-1 Views on Military Medicine
                                        ISxecutive hmmary




                                        equipment, the ability to provide continuity of care to patients, having
                                        to perform excessive amounts of quality assurance tasks, and the oppor-
                                        tunities to attend professional meetings and training.

                                        Dissatisfaction with certain factors does not necessarily result in a phy-
                                        sician’s decision to leave the service. GAO’S analysis of several of these
                                        factors indicates that active-duty physicians’ intentions to leave are
                                        influenced by: (1) the time spent on nonphysician tasks, (2) a gap
                                        between military and civilian physician compensation, and (3) the lack
                                        of opportunity to practice in their primary specialties. The number of
                                        hours that initial obligees are required to devote to readiness training
                                        also affects their intentions to leave. Physicians who are beyond their
                                        initial obligations are influenced by the number of unwanted permanent
                                        changes of station. Further analysis suggests that, among these factors,
                                        the probability of physicians leaving military service can be most effec-
                                        tively reduced by increasing compensation, by decreasing the time phy-
                                        sicians spend on nonphysician tasks, or both.

       I


GAO’s Analysis

Many Physicians Will
Likely Leave the Military
Wheb Eligible to Do So
Table li Phyalcians Planning to Leave
the Military Upon Completion of Their   Figures are percentages
Obligation                                                                      Stated probability of leaving
                                        Physician category             70% or greater                        50% or greater
                                        Overall                                    47                                    62
                                        Army                                       41                                    58
                                        Navy                                       50                                    65
                                        Air Force                                  52                                    63
                                        Obstetricians/Gynecologists                60                                    74
                                        Surgeons                                   51                                    67
                                        lnternal medicine                          46                                    64
                                        Primarv care                               42                                    56
                                        Support medicine                           71                                    78
                                        Initial militarv obliclation               62                                    77
                                        Beyond initial obligation                  28                                    42




                                        Page 3                                      GAO/HRD-99-l Views on Military Medicine
                                        Executive Summary




Physicians Dissatisfied                 Slightly more than one-half of the physicians said they were dissatisfied
With Several Aspects of                 with their pay and believed that private sector physicians earned 25 to
                                        100 percent more than they do. Support medicine Physicians, such as
Mi$itary Medicine                       anesthesiologists and radiologists, were the most dissatisfied and pri-
    I                                   mar-y care doctors were the least dissatisfied with their pay. (See p. 22.)

                                        Table 2 shows the extent of physician dissatisfaction with other aspects
                                        of military medicine.

Tab/e 2: Phyricians Dissatisfied With
Ceyin Aspects of Military Medicine                                                                                     Percent of
                                        Aspect of military medicine                                                    physicians
                                        Too few clerks, receptionists, and secretaries                                          86
                                        Too few nurses, corpsmen, and orderlies                                                 75
                                        Inadequate equipment in hospitals                                                       65
   /
                                        Unable to provide continuous care                                                       62
                                        Insufficient opportunities to attend professional meetings                     -63
                                        Excessive quality assurance tasks                                                       63
                                        Too little emphasis on medical proficiency in promotion decisions                       60




Factors Influencing                     Because questionnaire respondents identified compensation and the lack
Physicians Intentions to                of support personnel as primary inducements to leave, GAO'S analysis
                                        focused mainly on how these two factors affect physicians’ probability
Leave                                   of leaving. For example, increasing the average salary by $10,000 for
                                        physicians serving under their initial obligations reduces their average
                                        probability of leaving by an estimated 14 percentage points. The same
                                        salary increase for other obligees causes an estimated lg-percentage-
                                        point reduction in their stated probability of leaving. (See p. 28.)

                                        Initial obligees spend, on average, 11.3 hours per week on nonphysician
                                        tasks, such as nursing, secretarial, or administrative duties. Other obli-
                                        gees spend, on average, 8.4 hours per week on these tasks. Eliminating
                                        the time spent on nonphysician tasks decreases the stated probability of
                                        leaving by 5 percentage points for initial obligees and by about 10 per-
                                        centage points for other obligees. (See p. 30.)

                                        Other factors affect physicians’ stated probability of leaving, but their
                                        effects are small. For example, reducing the number of unwanted per-
                                        manent changes of station to 0 achieves a 3-percentage-point decrease in
                                        probability of leaving for other obligees. Eliminating readiness training
                                        entirely yields a l-percentage-point decrease in probability of leaving



                                        Page 4                                             GAO/HRD+O-1 Views on Military Medicine
                  Executive Summary




                  for initial obligees. Finally, if physicians’ dissatisfaction with their abil-
                  ity to maintain specialty skills was eliminated, the probability of leaving
                  would decrease, on average, by about 1 percentage point for initial obli-
                  gees and 4 percentage points for other obligees. (See p. 32.)


                  GAO   is making no recommendations.
Recdmmendations

                  As requested by the Chairman, GAO did not obtain written agency com-
Agency Comments   ments on a draft of this report. However, the views of responsible DOD
                  officials were sought and incorporated where appropriate.




                  Page 5                                    GAO/HRDN-1   Views on Military Medicine
@dents


Ekecutive Summary
Cl+apter 1
Introduction            Military Physician Force
                        Physician Attrition
                        Objectives, Scope, and Methodology

Chapter 2                                                                                            14
Characteristics of      Medical Education and Experience
                        Obligation Status
                                                                                                     14
                                                                                                     16
Military Physicians     How and Why Physicians Entered the Military                                  17
  1                     Physicians’ Primary Activities                                               18
                        Opportunity to Practice Medical Specialty                                    19

Chapter 3                                                                                            20
Ektent of Physician     Many Physicians Indicated a High Probability of Leaving
                            the Military
                                                                                                     20
Dissatisfaction With    Physicians Dissatisfied With Their Compensation                              21
Military Medicine       Inadequacy of Support Staff                                                  22
                        Physicians’ Views on Other Aspects of Military Medicine                      24

Cl+apter 4                                                                                           26
Fqctors That Most       Impact of Pay on Stay/Leave Decision
                        Impact of Nonphysician Tasks on Stay/Leave Decision
                                                                                                     27
                                                                                                     29
Influence Physicians’   Ability to Maintain Proficiency in Area of Specialization                    31
Plans About Military    Combat Readiness Training                                                    31
                        Permanent Changes of Station                                                 31
Service                 Summary                                                                      32

Appendixes              Appendix I: Physicians Planning to Leave the Military                        34
                            Upon Completion of Their Obligation
                        Appendix II: Physician Views on the Adequacy of Health                       35
                            and Administrative Support Personnel
                        Appendix III: Survey and Data Analysis Methodology                           38
                        Appendix IV: Major Contributors to This Report                               50

Tables     y            Table 1: Physicians Planning to Leave the Military Upon                       3
                            Completion of Their Obligation




                        Page 6                                   GAO/HRD-!%I Views on Military Medicine
Contents




Table 2: Physicians Dissatisfied With Certain Aspects of                      4
    Military Medicine
Table 1.1: Physician Losses by Service                                       11
Table 1.2: Ph sician Attrition Rates by Service                              12
Table 2.1: Yea6 of Experience of Military Physicians, by                     16
    Service
Table 2.2: Physicians Saying They Spent Time Performing                      19
    Certain Tasks
Table 3,l:Physicians Dissatisfied With Pay, by Medical                      22
    Specialty Group
Table 3.2: Physicians Who Believe Health Staff Is                           23
    Insufficient
Table 3.3: Physicians Who Believe Administrative                            23
    Support Personnel Is Insufficient
Table 4.1: Estimated Effect of a $10,000 Salary Increase                    28
    on Initial and Other Obligees’ Stated Probability of
    Leaving the Military
Table 4.2: Estimated Effect of a $10,000 Salary Increase                    28
    on Various Specialists’ Probability of Leaving the
    Military (Initial Obligees)
Table 4.3: Estimated Effect of a $10,000 Salary Increase                     29
    on Various Specialists’ Probability of Leaving the
    Military (Other Obligees)
Table 4.4: Estimated Impact of Eliminating Nonphysician                     30
    Tasks on Initial and Other Obligees
Table 4.5: Estimated Impact of Eliminating Nonphysician                     30
    Tasks on the Probability of Leaving the Military, by
    Medical Specialty Group
Table 4.6: Impact of Potential Personnel Policies on                        32
    Retention of Military Physicians
Table I. 1: Physicians Planning to Leave the Military Upon                  34
    Completion of Their Obligation (By Service)
Table 1.2: Physicians Planning to Leave the Military Upon                   34
    Completion of Their Obligation (By Medical Specialty
    Group)
Table 1.3: Physicians Planning to Leave the Service Upon                    34
    Completion of Their Obligation (By Type of
    Obligation)
Table II. 1: Internal Medicine Physicians’ Views on                         35
    Adequacy of Support Staff
Table II.2 Obstetrician/Gynecologists’ Views on Adequacy                    36
    of Support Staff



Page 7                                  GAO/HRD-90-l Views on Military Medicine
          Contents




          Table 11.3:Primary Care Specialists’ Views on Adequacy                       36
              of Support Staff
          Table 11.4:Medical Support Specialists’ Views on                             37
              Adequacy of Support Staff
          Table 11.5:General and Other Surgical Specialists’ Views                     37
              on Adequacy of Support Staff
          Table III. 1: Random Sample Selection-By Service and                         39
              Stratum
          Table 111.2:Estimates of Regression Equations for Initial                    46
              and Other Obligees

Figures   Figure 2.1: Percent of Physicians Who Completed                              15
               Residency and 1 Year of Post-Graduate Training
          Figure 2.2: Percent Distribution of Physicians by Type of                    16
               Obligation
          Figure 2.3: Physicians’ Obligation Status by Service                         17
          Figure 2.4: Five Most Important Reasons for Physicians                       18
               Entering the Military
          Figure 3.1: Physicians’ Interest in Civilian Employment                      21




          Abbreviations

          AFHPSP     Armed Forces Health Professions Scholarship Program
          CHAMPUS    Civilian Health and Medical Program of the Uniformed
                         Services
          DOD        Department of Defense
          GAO        General Accounting Office
          GME        graduate medical education
          Ob/Gyn     obstetrics/gynecology
          USUHS      Uniformed Services University of the Health Sciences


          Page 8                                  GAO/HRBI)O-1 Views on Military Medicine
Page 9   GAO/HRLNO-1 Views on Military Medicine
                     The Department of Defense (DOD) health care system has two primary
                     objectives. The first is to maintain the health of the active-duty force of
                     the uniformed services and be prepared to attend the sick and wounded
                     in wartime.1 The second is to provide medical care to eligible dependents
                     and retirees when space, facilities, and staff are available.

                     DOD  maintains over 500 military treatment facilities, ranging in size from
                     small clinics with limited capabilities to large hospitals with extensive
                     capabilities and medical teaching programs. Military treatment facilities
                     serve almost 9 million beneficiaries: 2.3 million are active-duty mem-
                     bers, 2.8 million are dependents of active-duty members, and 3.7 million
                     are retirees and dependents of retired or deceased members.

                     DOD  records show that the estimated cost of medical care at military
                     treatment facilities, exclusive of medical facility construction costs, was
                     about $10.2 billion for fiscal year 1989. When care is unavailable at mili-
                     tary treatment facilities, nonactive-duty beneficiaries may seek care
                     from civilian providers through the Civilian Health and Medical Pro-
                     gram of the Uniformed Services (CHAMPUS). CHAMPUS costs in fiscal year
                     1989 were about $2.5 billion.


                     To help meet its health care responsibilities, at the end of fiscal year
Military Physician    1988 DOD had approximately 13,000 active-duty physicians: 5,295 in the
Force                Army, 3,983 in the Air Force, and 3,929 in the Navy. Each service has a
                     medical department headed by a Surgeon General who is responsible for
                     the activities of the services’ medical facilities. The Assistant Secretary
                     of Defense (Health Affairs) is responsible for providing overall supervi-
                     sion and policy guidance for DOD medical care activities.

                     There are three major ways in which the military services recruit mili-
                     tary physicians: (1) the Armed Forces Health Professions Scholarship
                     Program (AFHPSP), (2) the Uniformed Services University of Health Sci-
                     ences (IJSUHS), and (3) direct recruitment of trained physicians. For the
                     first two sources, the military services finance the physicians’ medical
                     education in exchange for their agreement to practice medicine as an
                     active-duty military physician. In general, the number of years of active
                     duty required matches the number of years of medical training financed
                     by the military for AFHPSP physicians. The minimum obligation is 2

                     ‘The uniformed services include the Army, Navy, Air Force, Marine Corps, Coast Guard, and Com-
                     missioned Corps of the Public Health Service and of the National Oceanic and Atmospheric
                     Administration.



                     Page 10                                              GAO/HRD-90-l Views on Military Medicine
                                         Chapter 1
                                         Introduction




                                          years. For USUHS graduates, the active-duty obligation is 21 months for
                                          each year, or portion thereof, spent in medical training, except that in no
                                          case is the minimum obligation less than 27 months. Therefore, physi-
                                          cians who joined the military either through AFHPSP or USUHS are in obli-
                                          gated status for several years after completing medical school.
                                          Generally, physicians’ pay-back periods do not start until completion of
                                         their post-graduate training, (e.g., residency). Volunteers (those who
                                         joined the military as fully trained physicians) do not have an obligated
                                         pay-back period.


                                         As table 1.1 shows, between fiscal years 1985 and 1988, the number of
Physician Attrition                      active-duty military physicians leaving the services increased by 222 or
                                         about 12 percent.2 As of fiscal year 1988, DOD had 13,207 physicians on
                                         active duty.

Table i.1: Physician Losses by Servlce
                                                                                            Fiscal year                                 Chan e
                                                                        1985            1986              1987          1988          1985-19 8,8
                                         Air Force                        438             472              472            529                     91
                                         Army                             404             518              552            511                    107
                                         Navy                             431             426              448            455                     24
                                         Total                         1,273           1,416           1,472           1,495                     222
                                         Note: Includes personnel released/retired during the reporting period and physicians on inter-service
                                         and intra-service transfers, but excludes physicians in GME


                                         As a proportion of the total number of active-duty physicians, attrition
                                         rose from 13.7 percent in fiscal year 1985 to 15.6 percent in fiscal year
                                          1988, excluding physicians in GME programs. Attrition rates increased
                                         since 1985 in all three services, but the increases were greatest in the
                                         Army and Air Force as shown in table 1.2. The Army’s attrition rate
                                         rose by almost 25 percent and the Air Force attrition rate by about 13
                                         percent. By contrast, the Navy’s attrition rate rose by about 5 percent.
                                         Overall, however, the Army’s attrition rates have consistently been the
                                         lowest among the services.




                                         2These data do not include physicians who were in graduate medical education (GME) programs.
                                         GMETsometimes &led residency training, refers to the period physicians spend in post-graduate
                                         trammg in a medic&l specialty.



                                         Page 11                                                   GAO/HRD-90-l Views on Military Medicine
                                          Chapter 1
                                          Introduction




  /
      1.2: Physician Attrition Rates by
        (Excluding GMEs)
                                                                                      Fiscal Year
                                                                         1985        1986     1987         1988
                                          Air
                                          -~ Force                         15.1       15.5       15.1        17.0               1.9             12.6
                                          Army                             11.3       13.9       15.0        14.1               2.8             24.8
                                          Navy                             15.2       14.7       15.4        16.0               0.8              5.3
                                          Total                           13.7       14.7        15.1       15.6                1.9             13.9
                                          Note: These attrition rates reflect the year-to-year fluctuations caused by new recruitment of physicians
                                          as well as by physician losses. They exclude physicians in GME programs.


                                          To encourage more physicians to remain in the military, the National
                                          Defense Authorization Act for Fiscal Year 1989 established a medical
                                          officer retention bonus. Up to $20,000 per year is paid to physicians
                                          with 8 or more years of military service who agree to remain on active
                                          duty for at least 2 more years. The bonus program has been referred to
                                          by the Chairman of the Subcommittee on Military Personnel and Com-
                                          pensation, House Armed Services Committee, as a stop-gap measure to
                                          retain experienced military physicians.

                                          In addition, as the act directed, the Secretary of Defense reported on the
                                          adequacy of the existing compensation package for health care profes-
                                          sionals and submitted a proposal for a compensation system linked to
                                          earnings of physicians in the private sector. DOD also reported on
                                          noncompensation factors affecting physician retention.


                                          On August 19,1988, the Chairman, Subcommittee on Military Personnel
Objectives, Scope,and                     and Compensation, House Committee on Armed Services, asked us to
Meithodology                              develop and administer a questionnaire to physicians on active duty to
                                          elicit their views concerning factors that most directly influence their
                                          decision to remain in or to leave the military. The questionnaire we
                                          developed elicited information on several issues, including compensa-
                                          tion, support staff, time spent on various medical and nonmedical tasks,
                                          patient mix, training, professional development opportunities, nonmedi-
                                          cal aspects of military life, reasons for entering the military, and the
                                          probability of leaving it.

                                          We sent the questionnaire to 1,515 active-duty physicians, about 500
                                          from each branch of service, based on a stratified random sample of all
                                          active-duty physicians except those in GME programs. We excluded phy-
                                          sicians enrolled in GME because they are several years away from mak-
                                          ing decisions about their plans to leave or remain in the military. In



                                          Page 12                                                   GAO/HRD-90-l Views on Military Medicine
chapter 1
Introduction




consultation with DOD officials and GAO’S Chief Medical Advisor we
grouped physicians into five strata: (1) obstetrics/gynecology (Ob/Gyn),
(2) primary care (e.g., family practice, general medicine), (3) internal
medicine, (4) surgical specialties, and (5) support medicine (e.g., anes-
thesiologists, radiologists). Appendix III provides additional examples of
medical specialties included in each strata.

The survey was conducted between November 1988 and January 1989
and achieved a response rate of 85 percent.” The respondents are repre-
sentative of military physicians in general and, therefore, their
responses can be generalized to all active-duty military physicians.

In order to gain further insight into the factors that influence physi-
cians’ probability of leaving the military, we analyzed survey responses
using multiple regression analysis. This analysis focused on the correla-
tion between physicians’ stated probability of leaving and several inde-
pendent variables, such as compensation and hours spent on
nonphysician tasks. This method also allowed us to predict the change
in the probability of leaving that would be associated with a given
change in an independent variable, assuming the other factors that
might affect probability of leaving were held constant and physicians do
what they say they will.

Appendix III describes in more detail the sample selection and data anal-
ysis methodologies we used. Our work was performed between August
1988 and September 1989 in accordance with generally accepted gov-
ernment auditing standards.




“On March 16, 1989, GAO testified before the Subcommittee on Military Personnel and Compensa-
tion, House Committee on Armed Services, on preliminary results of its survey.



Page 13                                             GAO/HRD-90-l Views on Military Medicine
I


    Chapter 2

    Characteristicsof Military Physicians


                            This chapter describes the active-duty physician population and how
                            they spend their time as depicted by the questionnaire respondents.
                            Besides demographic data, information is presented on physicians’ medi-
                            cal education and experience, the proportion of physicians in each medi-
                            cal specialty group, how and why physicians entered the military, and
                            the extent to which they practice in their specialty.

                            Overall, military physicians are relatively young-the median age is 35
                            years, Eighty-eight percent are male. Nearly all received medical train-
                            ing in the United States and most are certified by medical specialty
                            boards in one or more specialties. The majority of physicians are in pri-
                            mary care specialties. Generally, military physicians reported that they
                            practiced in their specialties or subspecialties and that the primary
                            activity through their career has been to deliver medical care or to
                            engage in clinical activities.



    Mebical Education and   United States; 7 percent were graduates of foreign medical schools. Fig-
    Experience              ure 2.1 shows the level of professional medical education achieved by
                            physicians in each of the services.




                            Page 14                                  GAO/~99-l   Views on Military Medicine




                                                                                                       ..
                                        Chapter 2
                                        Characteristics       of Military Physicians




Flgure 7.1: Percent of Physlclans Who
Compl?ted Residency and 1 Year of
                                        Percent of Physiclam,
PostGraduate Training
       I




                                               Ait           Amy        Navy    Total
                                               Force

                                               1          1 post-grad Year 1
                                                           one full residency



                                        About 60 percent of all physicians are certified by medical specialty
                                        boards in one or more specialties. Across all services, the largest number
                                        of board-certified physicians is in family practice (primary care stra-
                                        turn)-96 percent of all family practitioners are board certified. Emer-
                                        gency medicine physicians (primary care stratum) have the lowest
                                        proportion of board certification-27    percent are board certified in
                                        their specialty.

                                        On average, physicians in the military have practiced medicine for about
                                         10 years, including post-graduate training. Military physicians, in gen-
                                        eral, have practiced medicine in a nonmilitary setting for an average of
                                        4 years, including physicians entering through AFHPSP who participated
                                        in internship and residency programs at civilian medical schools as well
                                        as those who joined the service as fully trained physicians. As shown in
                                        table 2.1, the total number of years military physicians have practiced
                                        medicine varies slightly among the services.




                                        Page 15                                         GAO/HRDQO-1 Views on Military   Medicine
                                                                                                                                                       I
      I




                                              Chapter 2
                                              characteristics   of Miku-y   Physicians




Table i2.1: Years of Experience of Military
Physi :ians, by Service                       Figures are percentages
                                                                                                Year of experience
                                              Branch of            Less than 5                                                               over 21
                                              service
                                              --                         years       6-10 years       11-15 years          16-20 years         years
                                              Army                            32                35               18                 14            3
                                              Navy                            33                34               16                 12            6
                                              Air Force                       41                23               22                 12            3
                                              Note: Columns do not add to 100 due to rounding



                                              Figure 2.2, shows the percent of military physicians serving their initial
Obligation Status                             obligations; that is, “paying back” the military for financing their medi-
                                              cal education; the percent of military physicians serving under some
                                              other type of obligation incurred as a result of participation in physician
                                              special pay programs, additional training, or promotions; and the per-
                                              cent of military physicians serving under no obligation.


FIgur? 2.2: Percent Distribution of
Physicians by Type of Obligation
                                                                                                      No Obligation




                                                                                                      Initial Obligation




                                                                                                      Other Obligation
                                              Physicians under initial obligation are those paying back for their medical education with a
                                              comparable number of years of military service.

                                              Figure 2.3 shows the obligation status of physicians by service
                                              affiliation.




                                              Page 16                                                  GAO/HRD-90-l Views on Military Medicine
 .
                                            chapter 2
                                            characterietlcs     OiMllltary         Physlclans




FlgurG 2.3: Phy@lclane’ Obligation Status
by S@vlco


                                             90

                                             80

                                             70

                                             60

                                             so

                                             40

                                             20

                                             20

                                             10

                                             0

                                                  Air          AMY          Navy
                                                  Force


                                                  L-l         No Obligation
                                                              Other Obligation
                                                              Initial Obligation


                                            Responses to our questionnaire indicated that about 52 percent of all
Ho% and Why                                 active-duty physicians entered the military through AFHPSP. About 16
Ph$sicians Entered                          percent entered voluntarily as fully trained physicians. About 6 percent
the’ Military                               came in through USUHS. The remaining 28 percent of physicians entered
                                            as draftees, through other draft-related programs, or joined the military
                                            in another capacity and later opted to pursue a military medical career.
                                            Figure 2.4 shows the major reasons why physicians entered military
                                            service.

                                            One-half of the physicians on active duty were uncertain about whether
                                            to pursue a career in the military when they entered. About 29 percent
                                            of them said that they had not planned to pursue a career in the military
                                            while about 21 percent intended to do so at the time they entered.




                                            Page 17                                             GAO/HRD-!+@l Views on Military Medicine
                                          chapter 2
                                          Chruacteristica   of Military   Physicituw




Flgurd 2.4: Five Meet Important Rearone
for Phislcianr Entering the Military
                                          78    Percent of Physicians
                                          70
                                          66
                                          00
                                          65    -
                                          50
                                          45
                                          40
                                          35
                                          30
                                          25
                                          20
                                          16
                                          10
                                           6
                                           0
                                               ‘1



                                           Five most important mesons for entering



    /
                                          For almost three-fourths of physicians (71 percent), the primary activ-
Physicians’ Primary                       ity throughout their career has been to provide medical care or to
Activities                                engage in clinical activities. Of this 71 percent, almost three-fourths
                                          responded that providing medical care was their primary area of
                                          responsibility. About 17 percent said that management or administra-
                                          tion was their primary responsibility, and 12 percent were primarily
                                          involved in teaching, research, or other activities. There were virtually
                                          no differences among the three services in terms of physicians’ primary
                                          activities, except fewer Army physicians were involved in management
                                          or administrative activities than Air Force and Navy physicians. Table
                                          2.2 summarizes how responding physicians said they spent their time
                                          during a typical work week.




                                          Page 18                                      GAO/HRD-So-1 Views on Miitmy   Medicine
                                          Chapter 2
                                          Charactdstice of MilItary Physicians




Table 51.2:Physicians Saying They Spent
Time @formIng Certain Tasks               Figures are percentages
                                                                                                               Hours Der week                    Over
      I                                   lark                                                         0    l-5    6-10 11-20 21-40                40
                                          Medical care/teaching                                        3      5        5       11        46
                                                                                                                                        ___---      30
                                          Management/administrative                                   10     34       24       18        10          4
                                          Research                                                    77     17        4        1         1          0
                                          Quality assurance tasks                                     17     65       15        3         0          0
                                          Nonphysician health care                            -       33     44       16        6         1          0
                                          Nonphysician administrative                                 16     53       24        6         1          0
                                          Note: Nonphysician health care tasks are those normally performed by a nurse, orderly, or corpsman.
                                          Nonphysician administrative   tasks are those normally performed by clerks, receptionists,   secretaries, or
                                          administrative personnel.



                                          About 83 percent of physicians practiced in their primary specialty or
Opbortunity to                            subspecialty to a great extent. About 14 percent practiced in their spe-
Practice Medical                          cialty to some extent, and very few (about 3 percent) practiced in their
                                          specialty to little or no extent. The extent to which physicians practiced
Sp@alty                                   their primary specialty or subspecialty was similar in the Army, Navy,
                                          and Air Force.




                     w




                                          Page 19                                                   GAO/HRD-90-l Views on Military Medicine
Chapter 3

E$tent of Physician DissatisfactionWith
Military Medicine

                         Military physicians indicated a substantial degree of dissatisfaction with
                         various aspects of military medicine. Almost one-half of the respondents
                         indicated that there was a 70-percent or higher probability that they
                         will leave the military when they become eligible. Physicians expressed
                         dissatisfaction with their compensation, the lack of administrative and
                         health support personnel, the inadequacy of military medical facility
                         equipment, the inability to provide continuity of care to patients, and
                         too little emphasis being placed on medical proficiency in decisions to
                         promote military physicians. The lack of support for professional train-
                         ing and travel as well as requirements to perform some quality assur-
                         ance tasks, which in the physicians’ view do not improve quality of care,
                         are also sources of dissatisfaction.

                         The opportunity to practice their medical specialty was an aspect of mil-
                         itary medicine that physicians cited as an inducement to stay in the ser-
                         vice. They also expressed general satisfaction with the control they had
                         over choosing their duty stations.


                         Forty-seven percent of the physicians reported that the probability of
Many Physicians          their leaving the military when their current obligation expires was 70
Indicated a High         percent or greater. Sixty-two percent indicated at least a 50-percent
Probability of Leaving   probability of leaving. An estimated 3,000 of the physicians under obli-
                         gation who report a 70-percent or higher probability of leaving will be
the Military             eligible to leave before the end of 1992. Attrition at the rate suggested
                         by these numbers would correspond with DOD’S actual attrition rates
                         over the last 3 years.

                         Physicians serving under their initial military obligation reported about
                         twice the probability of leaving as did physicians serving under other
                         types of obligation. A higher percentage of obstetricians/gynecologists
                         and support medicine physicians reported a higher probability of leav-
                         ing the service than the other medical specialties. Army doctors indi-
                         cated the lowest probability of leaving. Appendix I shows the stated
                         probabilities of leaving by branch of service, medical specialty group,
                         and type of obligation.

                         Although we do not know whether physicians will act on their stated
                         intention to leave the military, figure 3.1 shows that many of the
                         respondents to our questionnaire have been contacted about civilian
                         employment and about one-third have taken action toward obtaining
                         civilian employment.



                         Page 20                                 GAO/HRD-So-1 Views on Military Medicine
                                               Chapter 3
                                               &tent of Physician Dissatisfaction         With
                                               Military Medicine




Figurd 3.1: Physicians’ Interest In Civlllan
Emplo/yment
                                               100    Pwcenl of Physicians

                                                90    -
                                                80

                                                70

                                                60

                                                50

                                                40

                                                30

                                                20

                                                10

                                                 0

                                                      1
                                                               l-n
                                                               L
                                                                 2
                                                                         L
                                                                           3          4

                                               1) Physician has been contacted about civilian position.
                                               2) Physician has initiated contact about civilian position

                                               3) Physician has applied or interviewed for a civilian position.

                                               4) Other activities to pursue civilian position.




                                               Fifty-three percent of the physicians said that they were somewhat or
Physicians                                     very dissatisfied with their pay and 88 percent said that physicians in
Dissatisfied With                              the private sector were better off than they were in terms of earnings.
Their Compensation                             More specifically, a majority of the military physicians we surveyed
                                               believed that physicians in the private sector earned substantially more
                                               than they did.

                                               Dissatisfaction with compensation was similar among Army, Air Force,
                                               and Navy physicians. However, physicians’ views on pay and on civilian
                                               earnings varied considerably by physician specialty. As shown in table
                                               3.1, support medicine physicians were the most dissatisfied with their
                                               pay and also were the most likely to believe that their civilian counter-
                                               parts earned significantly more.




                                               Page 21                                                      GAO/HI&D-%1 Views on Military Medicine
                                                            Chapter 3
                                                            Extent of Physician Dissatisfaction   With
                                                            Military Medicine




Table/3.1:Physlclans        Dlssatlsfled With Pay, by Medical Specialty Group
      I                                                                 Sur ical                    Internal                       support               All
View/Issue                                               Ob/Gyn_     specla3 ties                  medicine    Primary care       medicine      physicians
So&&hat        to.very dissatisfied with pay                             65 --            57              66         -   46              74              53
   ..      -.-~
  probability     -.--.----.---~~
                  of leaving
                       pay and 70-percent or higher
Dissatiisfied
       t        with                                                     41               27              29             21              52              26

&iievi d they &rkd         25 _.....
                                  - _.- less- --.-.
                               percent         than their                 0 .___           1               2               9               0               5
   civil ean counterparts
                ....--__--___~~~~_,____~~                                   .-_____
bel&k?d they earned between 25-100 percent                               39               34              50             71              17              56
   less; than their civilian counterparts
Believed they earned between 100-300 percent                             61               65              48             20              83              38
   lessi than their civillan counterparts


                                                            We asked physicians whether a change in their pay that indexed their
                                                            earnings to comparable specialists in private practice would affect the
                                                            probability that they would leave military medicine. Thirty-four percent
                                                            said that a pay package indexed to earnings of physicians in private
                                                            practice would have little or no effect on their decisions to stay in the
                                                            military. But 61 percent said that their probability of leaving would be
                                                            somewhat or greatly decreased if pay were indexed to that of physicians
                                                            in private practice. With regard to whether a bonus would serve as an
                                                            inducement to remain in the military, 71 percent of the physicians said
                                                            that it would provide at least some inducement to remain.


                                                            Nearly all military physicians were dissatisfied with the number of
Inaldequacy of Support                                      health or administrative personnel available to support them. The
Staff                                                       responses to our questionnaire regarding inadequacy of support
                                                            resources closely parallel our February 1989 report on the extent to
                                                            which military physicians perform administrative and clerical tasks.’

                                                            Generally, physicians indicated that the number of health personnel
                                                            staff, such as general duty nurses, physician assistants, X-ray and labo-
                                                            ratory technicians, and corpsmen was insufficient to support their work.
                                                            Table 3.2 shows the percentage of physicians who indicated either mod-
                                                            erate or extreme dissatisfaction with current levels of health support
                                                            personnel.




                                                            ‘DOD Health Care: Extent to Which Military Physicians Perform Administrative Tasks (GAO/
                                                                - 9- 53, Feb. 13,1989).



                                                            Page 22                                             GAO/HRD-m-1 Views on Military Medicine
                                           Chapter 3
                                           Extent of Physician Dissatisfaction   With
                                           MUhry Medicine




Table 3.2: Physicians Who Believe Health
Staff lai InsufficIent                     Type of 8taff                                                      Percentage of physicians
                                           Suraical nurses                                                                                 37
                                           Nurse anesthetists                                                                              27
                                           Nurse practitioners                                                                             41
                                           Nurse midwives                                                                     ---          16
                                           General dutv nurses                                                                             74
                                           Physician assistants                                                                            45
                                           X-ray technicians                                                                               47
                                           Laboratory technicians                                                                          58
                                           Corpsmen/orderlies                                                                              76


                                           As shown in table 3.3, physicians also expressed concern about insuffi-
                                           cient administrative and clerical support.

Table $3: Physicians Who Believe
AdmlnJdtrative Support Peraonnel Is        Type of personnel                                                  Percentage of physicians
lnsuffieient                               Administrative officers      -                                                                  30
                                           Medical records clerks                                                                          65
                                           Secretaries, clerks, receptionists                                                              86


                                           Anecdotes provided by our respondents illustrate the problem of lack of
                                           secretarial/typing support. One physician wrote:

                                           “Give me a receptionist/secretary       to help out in the office. (I have to do -all my typ-
                                           ing. I have no typing support.)”

                                           Another physician stated:

                                           “I type all my own correspondence, call all my own patients, and do much more
                                           secretarial work than is necessary.”

                                           And another:

                                           “Finally a comment on the lack of secretaries, etc. No problem, thanks to the Army
                                           I’ve learned to type close to 80 words/min. and I’m expert at using the Mackintosh
                                           System. I’ve purchased my own system ($3,000) and my troubles are solved.”

                                           There are no significant differences of opinion among Army, Navy, and
                                           Air Force physicians with regard to the adequacy of the current levels
                     w                     of administrative support personnel. When segregated by specialty
                                           groups, physicians viewed shortages of support personnel differently.
                                           Because different medical specialists require different types of health


                                           Page 23                                             GAO/HRD-90-l Views on Military Medicine
                         Chapter 3
                         Extent of Physician Dissatisfaction   With
                         Military Medicine




   /                     support staff, variations exist among the types of staff they consider to
   I                     be in short supply. Appendix II shows these variations by specialty
   I                     groups.

   I


                         About 66 percent of the physicians surveyed indicated dissatisfaction
     sicians’ Views on   with the way military treatment facilities are equipped; 62 percent were
      r Aspects of       dissatisfied with being unable to provide continuity of care to their
Military Medicine        patients; and about 60 percent were dissatisfied because they felt that
                         too little importance is placed on medical proficiency in promotion
   I                     decisions.

                         Over one-half of all military physicians indicated that they were some-
                         what to very dissatisfied with quality assurance requirements. About 63
                         percent considered they spent more time than needed performing tasks
                         associated with these requirements and about three-fourths also
                         believed that these tasks did not improve the quality of patient care.

                         Seventy-two percent of all military physicians believed that civilian
                         quality assurance requirements are less stringent than those in the mili-
                         tary. Very few (about 7 percent) believed the requirements were more
                         demanding in the private sector and about 22 percent thought that
                         requirements were comparable in both sectors.

                         Another aspect of military medicine with which physicians reported dis-
                         satisfaction was the inability to attend as many professional conferences
                         and seminars as their colleagues in the private sector. About 63 percent
                         of all physicians are somewhat to very dissatisfied with the amount of
                         time and travel funds for professional activities the military provides,
                         Although 89 percent reported receiving time off or travel funds for this
                         purpose at least once in their career, the average number of professional
                         events physicians attend each year is slightly over one. About 70 per-
                         cent believed that the military’s support for their professional develop-
                         ment was less than adequate.

                         When asked to identify the most important inducements to remain in the
                         military, the most frequently cited reason was the opportunity military
                         physicians have to practice their field of medicine/surgery or, if trained
                         in more than one field, the opportunity to practice the field of medicine
                         they prefer to practice. About 50 percent of the physicians said that the
                         opportunity to pursue a medical specialty was an inducement to remain
                         in the military. Almost 60 percent said that ability to maintain profi-
                         ciency was also an inducement to stay. Other inducements to stay in the


                         Page 24                                      GAO/HRD-90-l Views on Military Medicine
Chapter 3
Extent of Physician Dissatisfaction   With
Military Medicine




military include a desire to help assure that members of the Armed Ser-
vices receive quality medical care and the fact that military physicians
do not have to concern themselves with the patients’ ability to pay for
care.

On the whole, physicians are satisfied with the control they have over
choosing the locations to which they are assigned. Only 11 percent of all
physicians indicate that they are dissatisfied with the location of their
duty station.

Most physicians (about 84 percent) had undergone a permanent change
of station. On average, physicians changed stations about three times
during their military career but were generally willing to move. Forty-
three percent of all physicians had no preference about remaining in
their previous assignment or moving.

Deployments-being      stationed for an extended period of time in an
operational setting-occurred     with about one-third of all physicians.
The remaining two-thirds had never been deployed. The average dura-
tion of deployments was related to service affiliation. The average dura-
tion of Army and Navy deployments was about 5 months compared with
3 months for the Air Force. Approximately 75-percent of all Army and
Air Force physicians had never been deployed compared with 41 per-
cent of Navy physicians. In general, physicians do not express dissatis-
faction with the frequency of deployments in any of the services.




Page 26                                      GAO/HRD-90-l Views on Military Medicine
Chapter 4

Fa$ms That Most Influence Physicians’ Plans
Ak$outMilitary Service

                  Although many considerations are likely to affect an individual physi-
                  cian’s decision to leave the military, some are more important than
                  others. To identify the relative importance of various factors, we used
                  multiple regression to analyze the responses of the physicians we sur-
                  veyed. In this way, we estimated the change in the stated probability of
                  leaving associated with a given change in each of the independent fac-
                  tors we c0nsidered.l Our analysis identified several factors that have a
                  statistically significant impact on a physician’s stated probability of
                  leaving. Lower probabilities are associated with

              l higher levels of military pay (relative to civilian compensation),
              . less time spent on nonphysician tasks,
              . the ability to maintain proficiency in a medical specialty,
              l less time spent on combat readiness training, and
              . fewer undesired permanent changes of station.

                  The analysis was performed separately for physicians serving under
                  their initial obligation and for other obligees.2 The two groups were ana-
                  lyzed separately because they are likely to differ in their taste for mili-
                  tary life and, consequently, this may affect not only the probability of
                  leaving the military, but also the individuals’ responsiveness to factors
                  such as military pay or combat readiness training. On average, physi-
                  cians who serve beyond their initial obligations may be expected to have
                  a greater predilection for military service than physicians still serving


                  ’ In its 1988 Pay Study, DOD reported that increases in military pay are associated with measurable
                  reductions in attrition rates, although DOD’s estimate of the magnitude of the pay effect is smaller
                  than our estimate. In general, DOD’s approach, both in terms of methodology and variables consid-
                  ered, is similar, but not identical, to the approach used in this report. One important difference
                  between the two studies is that DOD’s data contained information on actual attrition rates, whereas
                  our study measures the impact of various factors on physicians’ stated intentions to leave the
                  military.

                  “At 6 to 6 years of service, most military physicians face the first stay/leave decision. This point
                  marks the end of the “pay back” period required by the agreement to serve as a miliary physician for
                  a number of years in exchange for having received a medical education from the military. In this
                  report, all grade O-4 physicians who responded “yes” to the question “Are you currently serving
                  under your initial obligation” are included in the initial obligees category.

                  Those physicians who do not leave the military at the end of their initial obligation incur additional
                  obligations by virtue of promotions, eligibility for certain special pays, permanent changes of station
                  or additional education. The length of this additional commitment varies. For this report, we included
                  in the other obliges category all grade O-6 and O-6 physicians and all those grade O-4 physicians who
                  responded “yes” to the question “Are you serving under any other type of obligation.”

                  About 10 percent of the survey participants responded that they are under no obligation, including
                  some who at the time of our survey were eligible for retirement. These physicians are included in the
                  other obligees category. Physicians under no obligation were not analyzed separately because the
                  sample size is too small to provide statistically meaningful results.



                  Page 26                                                 GAO/HRD-90-l Views on Military Medicine
                          Chapter 4
                          Factma That Most Influence Physlciane’
                          Plaua About Military Service




                          under their initial obligation -many of whom will decide to leave the
                          military at the end of that obligation.

                          Three factors were statistically significant influences for both groups of
                          physicians: military pay, the number of nonphysician hours, and ability
                          to maintain proficiency. For initial obligees the stated probability of
                          leaving is also affected by the number of hours per month spent on read-
                          iness training. Among other obligees, the intentions to leave are affected
                          by the number of undesired changes of duty station.

                          Of all the factors considered, military pay and nonphysician hours
                          appear to be the most important in achieving meaningful reductions in
                          physicians’ intentions to leave the military. While other factors are sta-
                          tistically important, even the complete elimination of the difficulty in
                          maintaining proficiency, unwanted changes of station, and hours per
                          month spent on readiness training result in minor reductions in the
                          probability of leaving.


                          Physicians’ responses to questions about the earnings of civilian physi-
Impact of Pay on          cians point to the importance of pay for the stay/leave decision. In gen-
Stay/Leave Decision       eral, military physicians stated a higher probability of leaving if they
                          thought that their civilian counterparts were much better off finan-
                          cially. For example, 83 percent of the medical support specialists
                          believed their civilian counterparts earned at least 100 percent more
                          than they did and 71 percent indicated a high probability (70 percent or
                          more) of leaving the military when eligible to do so. Conversely, only 20
                          percent of primary care specialists believed their civilian counterparts
                          earned at least 100 percent more than they did and only 42 percent indi-
                          cated a 70-percent or higher probability of leaving when eligible.

                          The regression analysis shows that when civilian compensation and
                          other factors are held constant, both initial and other obligees’ stated
                          probability of leaving decreases as military pay increases. This inverse
                          relationship between military pay and intentions to leave is statistically
                          significant. (Statistical significance is discussed and regression coeffi-
                          cients are shown in appendix III.)


Estimated Effect of a     Table 4.1 shows the estimated impact of a $10,000 increase in pay on
$10,000 Salar3;Increase   the stated probability of leaving for initial and other obligees earning
                          the mean salary.



                          Page 27                                  GAO/HRD-90-l Views on Military Medicine




                                                                                                      I,/
                                               Chapter 4
                                               Factora That Most Influence Physicians’
                                               Plans About Mllltaq Service




Table 4.1: Estimated Effect of a $10,000
Salary Increase on Initial and Other                                                                          Estimated percent        Percentage-
Obligees’ Stated Probability of Leaving                                                                    probability of leavin    point decrease
the Mqlitary                                                                      Current percent                    after $lO,OO8 in probability of
                                               Average military pay          probability of leaving                       increase          leaving
                                               $73,259 (initial)                                   80.5                        74.2                  14.3
                                               $84,257 (Other)                                     52.7                        33.9                  18.8
       I                                       Note: The source for salary data in this table is DOD’s Report to Congress entitled: Health Professionals
       I                                       Special Pays Study, December 1, 1988. Salary figures are based on mean initial and other obligees
                                               salanes usrng I-rscal Year 1989 regular military compensation plus variable special pay, additional spe-
                                               cial pay, board-certified pay, and incentive special pay for eligible specialties.


                                               By increasing the compensation of initial obligees $10,000, a decrease in
                                               the probability of leaving in the range of 11 .Oto 17.7 percentage points
                                               can be achieved, depending on individual salary levels. Similarly, a 7.1-
                                               to 20.3-percentage point reduction can be obtained for other obligees.

                                               If physicians act in accordance with their stated intentions, at current
                                               reported salary levels we expect that approximately 877 out of 1,000
                                               physicians under initial obligation would leave the military while 123
                                               physicians would stay. After a $10,000 pay increase, we expect that
                                               approximately 735 would leave and 265 physicians would stay. This
                                               represents an expected gain of 142 physicians. For other obligees, we
                                               expect that 538 of 1,000 physicians would leave the military while 462
                                               would stay. After a $10,000 increase, we expect that 375 would leave
                                               while 625 would stay. This represents an expected gain of 163
                                               physicians.


Est$matedEffect of a                           Table 4.2 shows that initial obligees who are primary care physicians
$ lOi   Salary Increase by                     are most influenced by a $10,000 salary increase and those who are ob/
                                               Gyn’s or in support medicine specialties are influenced the least.
Medical Specialties
Table 4.2: Estlmated Effect of a $10,000
Salary Increase on Various Specialists’                                                                                         Internal        Medical
Probability of Leaving the Military (Initial                                       Ob/Gyn        Surgery        Primary        medicare         support
Obligdes)                                      Average (mean) Military              $78,568       $77,754       $68,768           $68,568       $76,061
                                                 pay
                                               Current probability of                   90.0          86.5          72.5              82.9           90.7
                                                 leaving (percents)                                                                   -___-__
                                               Probability after salary                 78.1          71.6          48.1              62.9           79.0
                                                 increase cDercents\
                                               Decrease in probability                  11.9          14.9          24.4              20.0           11.7
                                                 (percentage points)




                                               Page 28                                                    GAO/HRD-90-1 Views on Military Medicine
                                             Chapter 4
                                             Factors That Most Influence Physicians’
                                             Plans About Military Service




                                             Table 4.3 shows that among other obligee specialists, internal medicine
                                             and medical support physicians appear to be the most influenced by a
                                             $10,000 salary increase. The predicted effects of this increase do not,
                                             however, differ very much between specialties.

Table 4.3: Estimated Effect of a $10,000
Salary’lncreaae on Various Specialists’                                                                          Internal    Medical
Probe ility of Leaving the Military (Other                                   Ob/Gyn     Surgery    Primary      medicine     support
Oblige ! s)                                  Average (mean) military     -   $94,861    $95,764    $80,842        $82,615     $87,783
                                                pay
                                             ._.~_____
                                             Current probability of              52.9      45.8       31.8           50.4         60.8
                                                leaving (percents)
                                             .-____-
                                             Probability after salary            36.0      29.8        17.1          31.6         42.4
                                                increase (percent)
                                             Decrease in probability             16.9      16.0        14.7          18.8         18.4
                                                (percentage points)




                                             Responses to our survey also suggested that physicians’ intentions to
Im@actof                                     leave the military are affected by the number of hours they spend on
Nonphysician Tasks                           nonphysician tasks. Physicians were dissatisfied with the number of
on Stay/Leave                                administrative and health support personnel and the number of hours
                                             they spent performing nonphysician tasks. Eighty-seven percent of the
Dedsion                                      physicians who were dissatisfied with the number of administrative and
                                             health support personnel available indicated a 70-percent or higher
                                             probability of leaving the military.

                                             The regression analysis results confirm that the number of hours spent
                                             on nonphysician tasks has a statistically significant impact on both ini-
                                             tial and other obligees’ stated probability of leaving (see app. III). Spe-
                                             cifically, as the number of hours per week spent on nursing, clerical, and
                                             administrative support tasks increases, the stated probability of leaving
                                             also increases.

                                             Table 4.4 shows the estimated impact that nonphysician hours have on
                                             physicians’ intentions to leave the service. Specifically, the table shows
                                             how much the probability of leaving would decrease if nonphysician
                                             hours were reduced to zero.




                                             Page 29                                         GAO/HRD-90-l Views on Miitary   Medicine
                                                                                                                                              Y



                                            Chapter 4
                                            Factors That Most Influence Physicians’
                                            Plans About Military Service




Table 4.4: Estimated Impact of
Eliminating Nonphysician Tar&k8on Initial   Average number of hours per                                         Decrease in probability of
and Other Obligeer                          week spent on nonphysician                Current probability of         leaving (percentage
                                            tasks                                         leaving (percent)                        points)
                                            11.3 (Initial)                                               88.5                           5.2
                                            a.4 (Other)                                                  52.7                           9.5


                                            For initial obligees, 863 physicians (of 1,000) reported working between
                                             1 and 20 hours per week on nonphysician tasks. Of these, 764 would
                                            likely leave the military while 99 would likely stay. By eliminating non-
                                            physician tasks for physicians, an estimated additional 44 physicians
                                            would likely stay in the military-an    increase over the original 99 of 44
                                            percent.

                                            For other obligees, 869 physicians out of 1,000 reported spending
                                            between 1 and 20 hours per week on nonphysician tasks. Of this
                                            number, 466 are likely to leave the military while the remaining 413 are
                                            likely to stay. If nonphysician tasks were eliminated, an estimated 81
                                            additional physicians would likely stay in the military-an    increase
                                            over the original 413 of about 20 percent.

                                            By medical specialty group, the average reduction in the probabilities of
                                            leaving caused by eliminating nonphysician tasks ranges from 4.1 to 9.5
                                            percentage points for initial obligees and from 7.6 to 9.8 percentage
                                            points for other obligees (see table 4.5).

Table; 4.5: Estimated Impact of
Elfminating Nonphysician Tasks on the                                    Initial obligees                         Other obligees
Probability of Leaving the Military, by                                                Decrease in                            Decrease in
MediCal Specialty Group                                                 Current       probability of             Current     probability of
                                            Medical               probabi;$;f                              probability of          leaving
                                             specialty                                 (perci~~                  leavin       CPerc;;;;f;
                                             wow                      (percent 7                               (percent 7    ____-
                                            Ob/Gyn                           90.0                  4.0              52.9          --    9.8
                                            Surgery                          86.5                  5.9              45.8                9.5
                                            Primary                          72.5                  9.5              31.8                7.7
                                            Internal medicine                82.9                  7.2              50.4                9.4
                                            Medical support                  90.7                  4.1              60.8                9.0




                                            Page 30                                              GAO/HRD-99-l Views on Miitary    Medicine
                         Chapter 4
                         Factora That Most Influence Physicians’
                         Plans About Military Service




                         In our questionnaire we asked physicians whether it was difficult to
Ability to Maintain      maintain proficiency in their specialty given the number, diversity, and
Prokiciency in Area of   complexity of the cases encountered. Physicians who believed the case
Spebialization           mix encountered in the military made it difficult or very difficult to
                         maintain proficiency in their area of specialization stated a higher
                         probability of leaving the military. While only 40 percent of all physi-
                         cians reported difficulty maintaining proficiency, the regression analy-
                         sis shows a statistically significant relationship between probability of
                         leaving and being able to maintain proficiency in a specialty.

                         Specifically, the regression shows that, holding constant all other fac-
                         tors influencing physicians’ intentions to leave, there is a significantly
                         higher probability of leaving for those physicians who said that they
                         had difficulty maintaining their specialty skills as compared with those
                         who did not have any such difficulty. If it were possible to entirely elim-
                         inate difficulty maintaining proficiency, initial obligees would be mini-
                         mally affected in their decision to leave (a decrease of 1.2 percentage
                         points in probability of leaving). The effect would be stronger on other
                         obligees, (a 4,2-percentage-point decrease in probability of leaving) but
                         this group reports a less than even chance of leaving the military.


                         We estimated the effect of combat readiness training and field exercises
Combat Readiness         on the physicians’ stated probability of leaving. Results of this analysis
Training                 indicated that for physicians serving under their initial obligation there
                         was a statistically significant relationship between the number of hours
                         spent on readiness training and the probability of leaving. Specifically,
                         as the number of hours spent on readiness training and field exercises
                         increases, the probability of leaving also increases. Reducing the number
                         of hours spent in readiness training to 0, however, only changes the
                         average probability of leaving by 1 percentage point. In any case, elimi-
                         nation of combat readiness training for military physicians is not consis-
                         tent with the primary mission of military medicine, which requires
                         physicians to provide care for the sick and wounded in combat
                         situations.


                         We asked physicians how many permanent changes of station they con-
Permanent Changesof      sidered to be undesirable and we estimated the effect of this factor on
Station                  their stated probability of leaving. The regression analysis results indi-
           Y             cate that as the number of unwanted changes of station increases there
                         is a statistically significant increase in the stated probability of leaving.



                         Page 31                                   GAO/HRD-90-l Views on Military Medicine
                                           Chnpter 4
                                           Factors That Must Influence Physicians’
                                           Plans About Military Service




                                           This relationship is true for other obligees only. For example, eliminat-
                                           ing unwanted changes of station would reduce the average probability
                                           of leaving by about 3 percentage points. However, it would be difficult,
                                           if not impossible, for DOD to completely eliminate unwanted changes of
                                           station.

     1


                                           The probability of leaving stated by physicians is affected by several
Sbary                                      factors as shown in table 4.6.

Tab14 4.6: impact of Potential Personnel
Polic es on Retention of Military          Figures are percentages
Phys 1cians                                                                                         Initial obligees       Other obligees
                                           ---                  __--
                                           Current stated probability
                                                               -___.__      of leaving                          88.5                  52.7
                                           Percentage-point decrease in the stated
                                               probability of leaving__-___
                                                                        when:
                                               Salary
                                           -_____-     is increased
                                                                  -.- by  $10,000
                                                                           ___--       -_____                   14.3                  18.8
                                           --  Nonphysician
                                                      II_-      tasks  are  eliminated                           5.2                   9.5
                                               Obstacles to maintaining proficiency are
                                           -~--- removed                                                         1.2                   4.2
                                                                                                                                       -
                                                                                                                                          .
                                           --. Combat readiness training is eliminated                           0.9               -~__
                                               Unwanted permanent changes of station are
                                                 eliminated                                                            .               3.2


                                           Our analysis of these factors indicates that this probability can be
                                           reduced most substantially by increasing salaries and/or by decreasing
                                           hours spent on nonphysician tasks. Other factors, such as ability to
                                           maintain proficiency, unwanted changes of station, and readiness train-
                                           ing, show statistically significant effects but are impractical or difficult
                                           for DOD to address given its wide-ranging peacetime and readiness
                                           missions.




                                           Page 32                                              GAO/HRDSO-1 Views on Military Medicine
Page 33   GAO/HRD-90-l Views on Military Medicine
,&&ndix        1

Physicians Planning to Leave the IMilitary Upon
C@mpletionof Their Obligation

                                             This analysis contains statistics showing by service, by medical spe-
                                             cialty group, and by type of obligation the percentage of physicians stat-
                                             ing certain probabilities of leaving the service upon completion of their
                                             obligation. Two stated probabilities of leaving are shown, 70 percent or
                                             greater and 60 percent or greater.


Table 1.1: Physicians Planning to Leave the Military Upon Completion of Their Obligation (By Service)
Figur s are percentages
Probability of leaving                                              Air Force                  Navy                 Army           All Physicians
70 getrcent or more                                                          52                     50                  41                      47
50 p&cent or more                                                            63                     65                  59                      62




Table 1.2: Physicians Planning to Leave the Military Upon Completion of Their Obligation (By Medical Specialty Group)
Figures are percentages
                                                                  Surgical         Internal                            support                 Ail
Probabilitv of leavina                              Ob/Gvn     specialties        medicine        Primarv care        medicine        phvsicians
70 percent
     ,     or more
              ..~_. -                                    60             51                46                  42              71                47
50 percent or more                                       75             68                65                  57              79                62




Table 1.3: Physicians Planning to Leave the Service Upon Completion of Their Obligation (By Type of Obligation)
Figures are percentages
Probability
    .,      of -.leaving     .._____                                         initial obligation          Other obligation          Ail physicians
70 percent or more                                                                             62                       28                      47
50 percent or more                                                                             77                       42                      62




                                             Page 34                                                GAO/H&D90-l      Views on Military Medicine
Appendix II

Physician Views on the Adequacy of Health and
A’dministrative Support Personnel

                                          This appendix shows the variations among the five medical specialty
                                          groups regarding the adequacy of health and administrative support
                                          staff. We asked the physicians to specify whether they had more than,
                                          fewer than, or as many as needed of the type of staff required to sup-
                                          port their work. Physicians viewed shortages of support personnel dif-
                                          ferently because certain specialists require different types of health
                                          support personnel. However, all physicians indicated their are fewer
                                          administrative support personnel than they need.

Table $1: Internal Medicine Physicians’
Vtews n Adequacy of Support Staff         Figures are percentages
(Percem)”
                                                                                                                                Do not need
                                                                                 Mor;;rt;         Fewer than   As yen;:;         this tysa7:
                                          Type of staff                                              needed
                                          Health support personnel
                                          Surgical nurses                                     0           23                1             75
                                          Nurse anesthetists                                  0           17                3             80
                                          Nurse practitioners                                 1           40                6             53
                                          Nurse midwives                                      1            9                5             85
                                          General dutv nurses                                 1           72                5             22
                                          X-ray technicians                                   0           42               30             47
                                          Corpsmen/orderlies                                  2           69               16             18
                                          Physician assistants                                2           36                7             55
                                          Lab technicians                                     1           70               11             18

                                          Administrative    support personnel
                                          Administrative Officers                           14            40               29             17
                                          Medical Records Clerks                             1            66               15             18
                                          Secretaries, Clerks, Receptionists                 1            91                8              0
                                          Note: Percents may not add to 100 due to rounding




                                          Page 36                                                 GAO/HRD90-1 Views on Military Medicine
                                         Appendix II
                                         Physician Views on the Adequacy of Health
                                         and Admtnistrative Support Personnel




TabId II.2 Obrtetrlcian/Qynecologlsts’
Vie* on Adequacy of Support Staff        Figures are percentages
                                                                                                                                 Do not need
                                                                                MzJ;r;            Fewnert;i;    As ye;ydtz        this tyra;:
                                         Type of staff
                                         Health support personnel
                                         Surgical Nurses                                      1            74            23                 2
                                         Nurse Anesthetists                                   1            57            39                 3
                                         Nurse Practitioners                                  0            78            19                 3
                                         Nurse Midwives                                       2            60            16                22
                                         General Duty Nurses                                  1            92             6                 2
                                         X-Ray Technicians                                    0            55            35                10
                                         Corpsmen/Orderlies                                   0            84            14                 2
                                         Physician Assistants                                 2            36            20                42
                                         Lab Technicians                                      0            77            15                 9

                                         Administrative    support personnel
                                         Administrative Officers                         26                26            44                 4
                                         Medical Records Clerks                           0                77            21                 1
                                         Secretaries, Clerks, Receptionists                  0             94                5              0
                                         Note: Percents may not add to 100 due to rounding.


Table 11.3:Primary Care Specialists’
Vle\irs on Adequacy of Support Staff     Figures are percentages
                                                                                                                                 Do not need
                                                                                More than         Fewnert;zi    AS many as        this tyza;;
                                         Type of staff                            needed                           needed
                                         Health support personnel
                                         Surgical Nurses                                     0             23             7                70
                                         Nurse Anesthetists                                  0             17            11                72
                                         Nurse Practitioners                                 1             44            17                38
                                         Nurse Midwives                                      1             15             3                81
                                         General Duty Nurses                                 1             71            11                17
                                         X-Ray Technicians                                   1             42            30                28
                                         Corpsmen/Orderlies                                  1             78             6                16
                                         Physician Assistants                                I             49            15                35
                                         Lab Technicians                                     1             56            25                18

                                         Administrative    support
                                                             ..    personnel
                                                                   .
                                         Administrative Officers                         18                30            40                13
                                         Medical Records Clerks                           1                65            25                10
                                         Secretaries, Clerks, Receotionists               2                84            12                 3
                                         Note: Percents may not add to 100 due to rounding




                                         Page 36                                                  GAO/HRDBO-1 Views on Military Medicine
                                          Appendix II
                                          Phyeician Views on the Adequacy of Health
                                          and Adminbtrative Support Personnel




Table Il.@:Medlcal Support Specialists9
Vlews or Adequacy of Support Staff        Figures are percentages
                                                                                                                                     Do not need
        /                                                                        Mo;;;ri;          Fewn;;;z;        As ye;%;;         this tyza$
                                          Type of staff
                                          Health support personnel
        ,                                 Surgical Nurses                                      0               46                9            45
        I                                 Nurse Anesthetists                                   3               34               17            47
                                          Nurse Practitioners                                  1               13                6             80
                                          Nurse Midwives                                       1                7                4             88
                                          General Duty Nurses                                  1               52                4             44
                                          X-Ray Technicians                                    1               58               16            24
                                          Corpsmen/Orderlies                                   1               56               10            33
                                          Physician Assistants                                 1               16                5            78
                                          Lab Technicians                                      1               32                9            59

                                          Administrative    support personnel
                                          Administrative Officers                           12                 36               20             32
                                          Medical Records Clerks                             2                 53               12             33
                                          Secretaries, Clerks, Receptionists                 2                 87                9              3
                                          Note: Percents may not add to 100 due to rounding


Table 11.5:General and Other Surgical
Specia(ist8’ Views on Adequacy of         Figures are percentages
Suppo* Staff                                                                                                                         Do not need
                                                                                 MoWWe”;           Fewnzrt.?rt~; As ye;%:;            this tyza;f
                                          Type of staff
                                          Health support persofkel
                                          Surgical Nurses __-                                  0               74               11             15
                                          --
                                          Nurse Anesthetists                                   1               56               26             17
                                          Nurse Practitioners                                  2               32               20             46
                                          Nurse Midwives                                       2               15               10             73
                                          General Duty Nurses                                  1               87                7              5
                                          X-Ray Technicians
                                          -.-                                                  1               62               24             13
                                          Corpsmen/Orderlies                                   1               80               17              2
                                          Physician Assistants                                 2               52               17             29
                                          Lab Technicians
                                          -__-____                                             1               61               26             13

                                          Administrative    support
                                                              .     personnel
                                                                    .
                                          Administrative Officers                           31                 24               38              7
                                          Medical Records Clerks                             2                 68               25              6
                                          Secretaries, Clerks, Receptionists                   0               88               11              1
                                          Note: Percents may not add to 100 due to rounding.




                                          Page 37                                                  GAO/HRD-99-l Views on Military Medicine
Appendix III

Skvey and Data Analysis Methodology


                            This appendix describes the sampling design and data collection tech-
                            nique we used, as well as survey response rates. Because the data we
                            report about military physicians are estimates that are based on a sam-
                            ple of all physicians, this appendix also presents the sampling errors
                            associated with these estimates. Further, this appendix describes the
                            regression model we used to gain further insight into the factors that
                            influence the probability of physicians leaving the military.


                            We surveyed a random stratified sample of about 500 physicians from
Shpling Design              each branch of the service who were on active duty as of July 1988. We
                            excluded all those whom the military considered interns or in graduate
                            medical education programs because they were several years away from
                            making a decision about their plans to leave or remain in the military.
                            About 3,600 physicians were in these programs, leaving a remaining
                            universe of approximately 9,600 physicians. We divided the remaining
                            physicians into five groups, or strata, based on their military-designated
                            medical specialty as shown below.



Five Medical Strata
and Examples of
Medical Specialties
Used in GAO Survey

Ob$tetrics/Gynecology
Sur@ons                 l Orthopedic Surgery
                        . General Surgery
                        l Neurosurgery

Internal Medicine       . Rheumatology
                        l Gastroenterology
                        . Endocrinogoly

Primary
     care               l General Medicine
                Y       . Family Practice
                        . Psychiatry




                            Page 38                                 GAO/HRD-90-1 Views on Military Medicine
                                          AppendixIlI
                                          Survey and Dnta Analysis Methodology




SuppcjrtMedicine                        . Anesthesiology
                                        . Radiology
                                        . Nuclear Medicine

                                          Officials from the services’ Offices of the Surgeons General and the
                                          Office of the Assistant Secretary of Defense for Health Affairs and GAO'S
                                          Chief Medical Advisor assisted us in grouping specialties. By stratifying
                                          our sample in this way, specialties with relatively few physicians were
                                          better represented in our overall sample than they would have been if
                                          we had drawn a simple random sample from each service.

                                          Table III.1 shows the total number of physicians in the universe in each
                                          stratum by branch of service, and the number of physicians we ran-
                                          domly sampled and surveyed from each stratum.

Table IIf.1: Random Sample Selection-
By Seryice and Stratum                                                    Number of physicians in     Number of physicians
                                                                                 universe                   sampled
                                                                             (As of July 1988)          (As of July 1988)
                                          Stratum                        Army Navy        Air Force Army Navy        Air Force
                                          Ob/Gyn              -            233     105          155     85      70             75
                                          Surgeons                         833     435          580    110     120    ___--   120
                                          Internal medicine              2,295   1,818        1,881    115     140            140
                                          Primary care                     558     153          215    105      80             85
                                          Support medicine                 298     210          210     85      90             85
                                          Total                          4,217 2,721          3,041    500    500             505


                                          For each service, this sampling methodology allows us to project data
                                          from our survey to all active-duty physicians in each stratum as well as
                                          to all active-duty physicians. In general, estimates are for active-duty
                                          physicians who had completed their internship and were not graduate
                                          medical students as of July 1988.


                                          We developed a standardized mail questionnaire to collect information
Questionnaire                             from our sample of physicians. We pretested the questionnaire with two
Development                               physicians from each branch of the service. Based on the results of these
                                          pretests and comments from officials in Health Affairs and each of the
                                          services and the GAO Chief Medical Advisor, we revised the question-
                                          naire before mailing it out in November 1988. A follow-up mailing was
                      ”                   conducted in December 1988. The questionnaire elicited information on
                                          several issues, including




                                          Page 39                                        GAO/HRD-90-l Views on Military Medicine
                      Appendix Ill
                      Survey and Data Analysis Methodology




                     satisfaction/dissatisfaction    with the number of hours worked;
                     satisfaction/dissatisfaction    with types and variety of patients treated;
                     time spent on clinical, research, management, administrative, or other
                     activities;
                   . frequency with which physicians practice their primary specialty;
                   . sufficiency/insufficiency    of health, administrative, and clerical
                     personnel;
                     amount of time spent on quality assurance tasks;
                     opportunities to attend professional conferences and seminars;
                     satisfaction/dissatisfaction   with compensation; and
                     reasons for entering the military and probability of staying or leaving.

  I

                     Of the 1,506 questionnaires we sent, 1,272 were returned, for an overall
Su$vey Responses     response rate of about 85 percent. Of the 1,272 respondents, 62 either
                     indicated that they were no longer active- duty physicians or did not
                     answer the question. Our overall study objective was to describe the
                     experience, opinions, and attitudes of active-duty military physicians.
                     Therefore, the estimates in this report are based on responses from the
                     1,220 known active-duty respondents. These respondents represent an
                     estimated 9,616 active-duty physicians out of the 9,979 physicians in
                     our original universe.

                     Because we are estimating the characteristics of military physicians
                     based on a sample of those physicians, there is an error or imprecision
                     associated with each of these estimates. This imprecision is usually
                     expressed as a sampling error at a given confidence level. Sampling
                     errors for estimates from this survey were calculated at the 95-percent
                     confidence level. For example, based on responses to our questionnaire
                     we estimate that 90 percent of all military physicians are currently
                     under some type of obligation to remain in the military. At a 95-percent
                     confidence level, the sampling error for this estimate is plus or minus 2
                     percentage points. This means that the chances are about 19 out of 20
                     that the actual percentage of physicians currently under some type of
                     obligation is between 88 and 92 percent.

                     While some of the estimates in this report pertain to all military physi-
                     cians, others are presented according to branch of service and/or spe-
                     cialty group. At a confidence level of 95 percent, the sampling error for
                     estimates for physicians across all services are generally less than plus
                     or minus 4 percentage points. When estimates are for the physicians in
                     the single service, sampling errors are generally plus or minus 7 percent-
                     age points or less.


                     Page 40                                   GAO/HRD-90-l Views on Military Medicine
                      Appendix III
                      Survey and Data Analysis Methodology




                      Estimates for specialty groups generally have sampling errors of plus or
                      minus 6 percentage points or less. Sampling errors for estimates involv-
                      ing a specific specialty within a service do not exceed plus or minus 11
                      percentage points.

                      Totals in tables throughout the report do not always add to the esti-
                      mated universe of physicians (9,616) because not all respondents
                      answered all the questions. Percent totals in tables do not always add to
                      100 due to rounding.


                      To account for differences in physicians’ stated probability of leaving,
Mulbiple Regression   we developed a model that contains many factors plausibly related to
Model and Analysis    the probability of leaving. We estimated the model using multiple regres-
                      sion, a standard statistical technique that quantifies the relationship
                      between a dependent variable and a set of independent variables.

                      Our dependent variable, described in detail on page 45, is closely related
                      to the probability of leaving that physicians stated in their question-
                      naire responses. The independent variables include such objective fac-
                      tors as military and civilian compensation, medical specialty, the
                      number of hours spent on nonphysician tasks, and hours per month in
                      combat training, as well as proxies for tastes or preferences-gender,
                      career plans at time of enlistment, and so on. The regression procedure
                      related the variation between physicians in their stated probability of
                      leaving to the variation in each of the independent variables, and esti-
                      mated the effect on the dependent variable of a given change in each
                      independent variable (holding the other independent variables
                      constant).

                      Based on the regression results, we calculated the change in the
                      probability of leaving that would be associated with a given change in
                      one independent variable, if the others remained unchanged. For exam-
                      ple, we calculated the change in the probability of leaving associated
                      with a $10,000 increase in military pay, assuming that the nonpay and
                      personal characteristics variables remained unchanged. We also calcu-
                      lated the change in the probability of leaving that would occur if the
                      time physicians spend on nonphysician tasks were eliminated, assuming
                      that the other independent variables (including pay) were held constant.




                      Page 41                                  GAO/HRD-90-l Views on Military Medicine
                               Appendix III
                               Survey and Data Analysis Methodology




The Model of Physicians’       After conducting bivariate analyses of our survey responses, we
Prdbability of Leaving         hypothesized that independent variables related to the physicians’
                               stated probability of leaving would fall into four categories:

                               1. Personal and demographic characteristics of the individual physician.

                               2. Military and civilian compensation.

  ,                            3. Noncompensation characteristics of the practice of military medicine.

                               4. Medical specialty.

                               All the variables in the regression model and their definitions are listed
                               in the following pages.

                               Our four categories of independent variables resemble categories drawn
                               from the standard economic theory of labor supply and occupational
                               choice, these categories are:

                           . compensation of military physicians and their compensation alternative
                             in the civilian sector,
                           l nonpay characteristics of both military and ,civilian medicine, and
                           l tastes or preferences of the individual physician.

                               Because the categories from economic theory are rigorously derived as
                               well as comprehensive, they provide a benchmark for assessing the ade-
                               quacy of our model.’ In addition, the theoretical categories provide a
                               precise, economic interpretation of several of our independent variables.
                               For example, the medical specialty variables in our model can be inter-
                               preted as reflecting nonpay characteristics of military medicine that are
                               included explicitly as independent variables-specifically,    the working
                               conditions peculiar to practicing a given specialty in the military.2 The
                               personal characteristics variables provide another example: they can be


                               ‘Two deviations of our model from the theoretical benchmark are noteworthy: first, economic theory
                               dictates including nonpay characteristics of both the current occupation (military physician) and the
                               alternative occupation (civilian physician), but we have data on nonpay variables only for the current
                               (military) occupation. Second, economic theory calls for including a civilian pay variable that meas-
                               ures-for each military physician-the compensation that would be earned by a civilian physician
                               with the same specialty, training, work history, and ability as the military physician in question.
                               Lacking such refined data, we used data on the average pay of civilian physicians in the same spe-
                               cialty and at the same rank as the military physicians. (See p. 46 for more detail.)

                               “The medical specialty variables may also reflect differences by specialty in civilian physician com-
                               pensation, because our measure of that pay concept (CIVPAY) is not perfect.



                               Page 42                                                 GAO/HRD-90-l Views on Military Medicine
                           Appendix III
                           Survey and Data Analysis Methodology




                           interpreted as proxies for differences in tastes that influence a physi-
                           cian’s evaluation of the objective features, both pay and nonpay, that
                           typify military medicine and civilian medicine.


Definitions of Variables   MALE = 1 if male
Used!in RegressionModel    MAR = 1 if married living together
                           DPND = number of dependents
                           CAR = 1 if planned military career when entered military
                           MILPAY = In (military pay), where military pay is estimated by DOD spe-
                           cialty and active duty grade
                           CIVPAY = In (civilian pay), where civilian pay is estimated by DOD spe-
                           cialty and academic rank
                           NONPHYS = In (hours per week spent on nursing, clerical, and adminis-
                           trative tasks)
                           MIX = 1 if difficult to maintain proficiency with case mix
                           PRSP = 1 if able to practice in specialty
                           CT = hours per month spent in readiness or combat training
                           DEP = average number of months deployed per year
                           PCS = number of unwanted permanent changes of station.
                           INT = 1 if specialty is an internal medicine specialty
                           PRIM = 1 if specialty is a primary care specialty
                           SURG = 1 if specialty is a surgery specialty
                           OBGYN = 1 if specialty is obstetrics/gynecology
                           SUPPORT MEDICINE used as reference group


Persbnal and Demographic   This category contains several demographic characteristics-gender
                           (MALE), marital status (MAR), and number of dependents (DPND), as well
Variables                  as a more direct indicator of personal preferences-whether   the physi-
                           cian planned on a military career when he or she entered the military
                           (CAR).


Military and Civilian      We chose, as our measure of military pay, the average salary for mili-
Compensation Variables     tary physicians by specialty and grade level (MILPAY).~ The source for
                           these average salary data is DOD. As our measure of the pay that alter-
                           native positions in civilian medical practice might offer military physi-
                           cians, we selected the average salary of teaching physicians by academic
                           rank-assistant   professor, associate professor, and full professor
              yi
                           “MILPAYis expressedasthe natural logarithm of the dollar salary, as is our measure of civilian
                           salaries (CIVPAY).



                           Page 43                                                GAO/HRD90-1 Views on Military Medicine
                   Appendix JlI
                   Survey and Data Analysis Methodology




-
                   (CIVPAY). DODtreated these ranks (Health Professions Special Pays
                   Study) December 1, 1988) as comparable to military physicians at pay
                   grades 04,06, and 06 (Army and Air Force: Major, Lt. Colonel, and
                   Colonel; Navy: Lt. Commander, Commander, and Captain). We excluded
                   pay grade 03 physicians from our regression analysis, because we
                   lacked DOD data on physicians with active duty grade 03 (Army and Air
                   Force: Captain; Navy: Lieutenant).

                   Academic salaries are not a perfect substitute for earnings in the private
                   sector (which has nonteaching physicians in clinical and administrative
                   roles). In addition, teaching medicine may not be the typical civilian
                   alternative for the military physician. Nonetheless, we used academic
                   salaries as a proxy for civilian earnings for two reasons. First, academic
                   salaries were the best civilian salary data readily available that per-
                   tained to civilian positions comparable to military physicians’ duties and
                   experience. Second, review of research on military physicians’ retention
                   and pay suggests that academic salary information provides a measure
                   of civilian physician compensation that is roughly as good as informa-
                   tion on nonacademic salaries. Specifically, a Congressional Budget Office
                   study, which used information collected by the American Medical Asso-
                   ciation on both academic and nonacademic salaries, found effects of
                   civilian pay on military physicians’ attrition that are similar to a DOD
                   study that used data only on academic salaries. Although information is
                   lost by using data only on academic salaries, evidently the academic
                   data vary sufficiently with civilian physician pay in general to permit
                   meaningful analysis of the relationship of pay to military physicians’
                   retention.4


Nonpay Variables   For the category of nonpay characteristics of the job of military physi-
                   cian, we chose variables that either are associated exclusively with the
                   practice of military medicine or apply to anyone in the military. These
                   variables include the adequacy of support personnel, measured by the
                   logarithm of the number of hours spent on nonphysician tasks
                   (NONPHIS); adequacy of case mix (MIX); whether physicians are able to



                   4Measurement errors, such as those affecting our civilian pay indicator, may cause the coefficient
                   estimate on CIVPAY to be biased toward zero. Also, this so-called “errors in variables” problem also
                   causes coefficient estimates to be less statistically precise than otherwise. This problem may explain
                   in part why the coefficient on CIVPAY is insignificant in the other obligees equation and why the
                   coefficient for civilian pay is substantially smaller than that for military pay in all equations. Accu-
                   racy in civilian pay may be more important for other obligees than initial obligees, because the civil-
                   ian opportunities for more experienced physicians (other obligees) may be more heterogeneous than
                   for less experienced physicians (initial obligees).



                   Page 44                                                   GAO/HRD-90-l Views on Military Medicine
                             Appendix III
                             Survey and Data Analysis Methodology




                             practice in their area of specialty (PRSP); hours per month spent in mili-
                             tary readiness (i.e., combat) training (CT); average number of months
                             deployed per year (DEP); and number of unwanted permanent changes of
                             station (PCs).


The I)ependent Variable      We formulated the dependent variable as the natural logarithm of the
and qrobability of Leaving   odds ratio, (Prob/(l-Prob)), where “Prob” denotes the stated probability
                             of leaving. The probability of leaving would be more intuitive as the
                             dependent variable, but it is prone to a statistical problem: a regression
                             model may predict a probability of leaving that exceeds 1 or is less than
                             O-a result that contradicts the meaning of probability. To avoid this
                             difficulty, it is conventional to define the dependent variable as the loga-
                             rithm of the odds ratio.


Initial and Other Obligees   We performed the regression analysis separately for physicians serving
Analyzed Separately          under their initial obligation (initial obligees) and for those serving
                             under some other form of obligation (other obligees). Analysis of the
                             physicians’ questionnaire responses revealed that these two groups
                             stated substantially different probabilities of leaving the military (on
                             average).

                             In addition, the two groups are likely to have, on average, different
                             tastes or preferences for military life and military medicine, objective
                             factors (pay, etc.) aside. Other obligees have, by accepting one or more
                             obligations beyond their initial obligation, revealed a preference for mili-
                             tary life and military medicine.6 By contrast, the group of initial obligees
                             contains both those physicians who will eventually incur a second obli-
                             gation and those physicians who will, when their initial obligation is up,
                             leave the military. Consequently, it is reasonable to assume that the ini-
                             tial obligees have a lesser taste for military medicine, on average, than
                             other obligees have. In addition, initial obligees and other obligees may
                             evaluate the particular objective features of military medicine (e.g.,
                             unwanted permanent changes of station) differently. Given these con-
                             siderations, economic theory suggests that the two groups be analyzed
                             separately.”
                             “At the end of their initial obligation, other obligees faced the same pay and nonpay characteristics of
                             military medicine as their colleagues who chose to leave the military. This strongly suggests that
                             other obligees have a greater taste for military life and military medicine than those who leave the
                             military.
                             “In economic terms, if the preference functions of the initial obligees differ from those of other obli-
                             gees, then the derived functions for probability of leaving will differ between the two groups as well.



                             Page 45                                                  GAO/HRD-90-l Views on Military Medicine
                                                          Appendix lI.I
                                                          Survey and Data Analysis Methodology




Results of Regression                                     We estimated the regression models for initial and other obligees by the
Analysis                                                  method of ordinary least squares. Table III.2 presents the estimates of
                                                          the regression coefficients for the two models of initial and other obli-
                                                          gees’ intentions to leave the military. The table also contains informa-
                                                          tion on the statistical precision (standard error and T-statistic) of each
                                                          coefficient estimate. An estimate is considered statistically significant if
                                                          the probability is low that the true value of the coefficient is 0. We chose
                                                          as our criterion a significance level of .lO; that is, we required that the
                                                          probability of the true coefficient being 0 is no greater than .lO.


Tablei 111.2:Estimates of Regression Equations for Initial and Other Obligees
Depehdent
._.               Variable=LN(Prob/(
  .._._-/-.“._-. ..___.
                     “.__..---                 1-Prob))
                                                                        Coefficient            Standard Error               T-Statistic                  Mean
Indeiendent               variable                                       Initial  Other           Initial Other             Initial    Other          Initial Other
MILPdY Military            pay                                           -7.71      -6.91            4.98       2.01        -1.55      -3.45           11.22      11.37
ClVPpiY
_ _ ..-., Civilian  pay
           .^.._-__--..-                                                   1.33       0.87           0.98       1.16          1.35       0.75          11.51      11.68
NONPHYS Nonphysician                   hrs.                                0.07       0.06           0.04       0.03          1.82       1.98           1.64       0.90
MIX Case mix                                                               0.26       0.44           0.20       0.22          1.30       2.00           0.44       0.38
PRSP’Practice     specialty                                              -0.26      -0.17           0.27        0.35        -0.96      -0.50            0.83       0.89
 .._ _.,.__. ...-__~.--
CT Rqadiness training                                                      0.02       0.00           0.01       0.01          1.90     -0.25            4.10       3.94
DEP deployments __~                                                        0.01     -0.14           0.12       0.13           0.10     -1.12            0.29       0.36
PCS Permanent chanae of station                                            0.12       0.14          0.12        0.09          1.02       1.45           0.46       0.94
MALE..,__._
       Male-.-.- ._.....-.                                                 0.01     -0.42           0.31       0.45           0.03     -0.95            0.86       0.94

_MS Marital status                                                       -0.14      -0.34           0.29       0.34         -0.47      -1 .Ol           0.85       0.87
 DPT
  -...--No.. ..._....___^_
  ..._._--      dependents-
               --_-._-..--_
                                         ---                               0.01       0.05          0.07       0.07           0.18       0.76           3.34       3.94
CAR Planned militarv career                                              -0.74      -0.10           0.25       0.29         -2.97      -0.35            0.19       0.17
INT ln$ernal medicine                                                    -0.97      -0.62           0.47       0.39         -2.08      -1.57            0.18       0.24
PRIM ‘Primary care                                                       -1.62      -1.52           0.51       0.43         -3.19      -3.51            0.10       0.24
      .-- _~-                    ..-
SURG       Surgery
..-.-_ ._,._.. -----II-                                                  -0.41      -0.07           0.28       0.35         -1.47      -0.20            0.29       0.23
OB Ob/Gvn                                                                  0.29       0.35          0.36       0.44           0.79       0.78           0.20       0.13
Constant                                                                 73.47      69.07          48.51      12.02           1.51       5.75
Adjusted
 ...____.._  R-square
        .._ ._..-----                                                      0.08       0.13
F-Statistic                                                                2.61       4.78
Sianifrcance        level of F-Statistic                                 0.001      0.000
No. of observations                                                        294        405

                                                          Note: “Prob” denotes physician’s stated probability of leaving military service. The adjusted R-square
                                                          measures the proportion of the variation in the dependent variable that is accounted for by the variation
                                                          in the set of explanatory variables. The F-statistic permits testing for the statistical significance of the
                                                          observed association between the dependent variable and the set of explanatory variables.


                                                          The sign of the coefficient indicates the direction of the estimated effect.
                                                          For instance, the negative sign on MILPAY indicates that an increase in



                                                          Page 46                                                      GAO/HRD-90-l Views on Military Medicine
     ,                     Appemiix III
                           Survey and Data Analysis Methodology




                           military pay results in a decrease in the stated probability of leaving.
                           The “T-statistic” permits the statistical significance of the effect to be
                           tested, Roughly, if the T-statistic if greater than 1.65 (1.28 for one-tailed
                           tests), the effect is considered “statistically significant” at the lo-per-
                           cent level.

                           As the T-statistics in table III.2 reveal, three variables-military    com-
                           pensation, number of hours spent on nonphysician tasks, and case
                           mix-have a statistically significant effect on the dependent variable
                           (and, therefore, on the probability of leaving) for both initial and other
                           obligees. Military pay is statistically significant, and has the expected
                           negative effect on the physicians’ stated probability of leaving.7 That is,
                           as military pay increases (holding civilian pay and other variables con-
                           stant), the stated probability of leaving decreases. The number of hours
                           per week that a physician spends doing nursing, clerical, and adminis-
                           trative tasks has a statistically significant, positive coefficient. As non-
                           physician hours (NONPHE) increases, the stated probability of leaving
                           increases. Finally, the coefficient on case mix is statistically significant
                           and positive. Physicians who said that they had difficulty maintaining
                           proficiency in their specialty also stated a higher probability of leaving.R

                           The regression results also indicate that initial obligees’ intentions to
                           leave are affected by several variables that do not affect other obligees’
                           intentions. These variables are: hours spent on readiness training (CT)
                           (positive effect), civilian pay (positive effect), and “planned a military
                           career at time of enlistment” (CAR) (negative effect).

                           One variable that does not affect initial obligees’ intentions does, how-
                           ever, influence the intentions of other obligees. That variable-the
                           number of undesired changes in permanent station-has a negative
                           effect.


Issues of Interpretation   The multiple regression methodology that we have employed has the
                           virtue that it provides quantitative answers to questions that are of cen-
                           tral importance to policy regarding retention of military physicians. In
                           particular, the survey data and regression estimates presented in chap-
                           ter 4 and in this appendix provide guidance on the effects of military

                           7The appropriate statistical test is one-tailed, because the alternative to the null hypothesis of no
                           effect was that the true coefficient is negative.
                           sin addition to these three variables, the set of medical specialty variables is statistically significant
                           for both initial and other obligees.



                           Page 47                                                    GAO/HRD-90-l Views on Military Medicine
Appendix III
Survey and Data Analysis Methodology




pay. This guidance is the best we can provide given the general state of
knowledge and the resources devoted to the study. As in any similar
study, however, care and caution are called for in the interpretation and
application of our results. This section discusses the principal qualifica-
tions and problems of interpretation that users of our study should be
aware of.

First, it should be emphasized once more that our dependent variable
relates to the stated probabilities of leaving the service that military
physicians expressed in response to our survey. The overall picture pro-
vided by their responses is reasonably consistent with actual experi-
ence, and many specific features of our results-such as the higher
separation probabilities indicated by initial obligees-are quite plausi-
ble. Nevertheless, we have not established a direct link between the
probabilities stated in the survey results and the actual decision of mili-
tary physicians to stay in the service or not.

Second, our estimates of the effects of the various independent variables
are relatively imprecise. In particular, although we have established, by
conventional statistical standards, that military pay does affect physi-
cian retention, the standard errors reported in table III.2 indicate that
we have not succeeded in measuring the strength of these effects with
precision. For example, it is roughly an even odds bet whether the esti-
mated value of the MILPAY coefficient for other obligees (-6.91) is within
+- 1.36 of the true value. Nonetheless, in our view, the figures presented
in chapter 4 on the effects of a $10,000 salary increase are a reasonable
basis for policy decisions. They do not, however, obviate the need for
further study or for close monitoring of the results if an attempt should
be made to address the retention problem through a salary increase.

Third, it is possible that our estimates are systematically biased away
from the true values. We have already noted that the explanatory vari-
ables provided in our data set are less than ideal from the viewpoint of
economic theory (page 44, footnote 1). Regarding civilian pay, we have
explained the sort of bias that might result (page 46, footnote 4). Other
possible sources of biased estimates might be adduced. We believe, how-
ever, that any theoretically plausible analytic framework would yield
similar results if applied to the same data or to better and more exten-
sive data of the same type.

In assessing the confidence of our conclusions, we paid particular atten-
tion to the following plausible argument suggesting that our estimates of
the effect of military pay might be too high: physicians whose tastes


Page 48                                  GAO/HRD-90-l Views on Military Medicine
Appendix III
Survey and Data Analysis Methodology




lead them to prefer military practice and life to the civilian alternative
tend both to remain longer in the military and to report lower probabili-
ties of leaving, compared with physicians who lack such a preference.
Because military pay generally rises with years of service, military pay
and “taste for military life” would mean an estimate of the pay effect
that is too high; part of our measured effect of higher pay would be
attributable to a stronger taste for military life.

Before evaluating this argument, we note that it illustrates a general
point about the type of analysis we have done. The Congress could raise
pay, but it presumably cannot raise physicians’ taste for military life at
the same time. It is precisely for this reason that we employed multiple
regression analysis to attempt to assess (among other things) what the
effect would be if military pay and nothing else were changed. In pursu-
ing this objective we attempted to control for taste effects by (1) divid-
ing our sample into two categories (initial obligees and other obligees)
that are very likely to differ on average in their taste for military life,
and (2) introducing a variable (CAR) into the model that indicated
whether a physician, upon enlistment, intends to pursue a military
career.

Recognizing that these efforts to control for taste factors might have
fallen short, we performed further analysis of the data on other obligees
to determine whether years of service in the military might have some-
thing to do with the relationship between pay and retention. We did find
some suggestions in the data that the physicians with more than 12
years of service (roughly one-half the sample) have lower stated
probabilities of leaving and are less responsive to pay than physicians
with fewer years of service. However, these indications are not so strong
as to lead us to reject at standard significance levels the hypothesis that
there is no difference between the groups with high and low years of
service. In addition, although physicians with more years of service col-
lectively report lower separation probabilities on average, they are quite
comparable to their colleagues in terms of the (large) amount of varia-
bility around that average. Thus, it is far from the case that all long-
tenured military physicians have simply decided that they are staying in
the service. Also, physicians with fewer years of service appear to be, if
anything, more responsive to military pay effects than we have esti-
mated. Overall, it seems clear that our estimate of the pay effect is not
merely an artifact associated with taste variables for which years of
service provides a proxy. And while it remains plausible that long-ten-
ured physicians are less responsive to pay than short-tenured physi-
cians, our data do not provide decisive support for this view.


Page 49                                  GAO/IiRIHO-1   Views on Military Medicine
   p&ndix IV

 &&r Contributors to This Report


                   David P. Baine, Director, Federal Health Care
H I an Resources
 T
Diyision,
                   Delivery Issues (202) 276-6207
                   Stephen P. Backhus, Assistant Director
Wzjshington,
   !
             DC.   William A. Hightower, Assignment Manager
                   M. Cristina Rey Gobin, Evaluator-in-Charge
                   Wayne M. Dow, Statistician
                   Clarita A. Mrena, Social Science Analyst
                   Jonathan Ratner, Assistant Director, Economic Analysis
                   James Cosgrove, Economist




(101343)           Page 50                               GAO/HRD-90-l Views on Military Medicine