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Back in 2017 Congress, in the National Defense Authorization Act, ordered the Defense Department to restructure its medical treatment facilities. It was in part to control costs and in part to support readiness. A mandated Government Accountability Office review finds, DoD relied on incomplete data for some of the work. The GAO’s director of Defense capabilities and management issues, Brenda Farrell, joined Federal Drive with Tom Temin with the highlights.
Tom Temin: This is a complicated thing they were tasked with doing but give us the big picture of what DoD is actually trying to do here in rescaling or reorganizing this whole TMF operation?
Brenda Farrell: Sure. This is a complex issue, as you said and DoD has been continuously challenged about how do they balance the military readiness mission with the mission to deliver high quality medical care to the beneficiary. And the mass reform efforts for the military health system actually began over a decade ago. This is one of several reforms that’s underway. When the reforms began this last time, the focus was on cost efficiencies. But in the past few years, the focus has shifted to the priority of military medical readiness. So Congress mandated, knowing how complex and how much care should be taken with this restructuring — Congress mandated DoD to provide the plan that you mentioned and then for DoD, to provide it to us we would review it before the action was taken by DoD or Congress and then they would move forward. It affects millions of people. It affects the mission. It has an outreach that hard really to understand and grasp.
Tom Temin: Yeah. So is part of this then taking a portion of care that may not be related to readiness, routine care, and trying to shift it to providers outside of the military system itself.
Brenda Farrell: Exactly. That’s part of it the mandate to DoD establish some statutory elements. And we found that DoD did use and prioritize those statutory elements. The first being to determine the support each MTF provides to service members medical readiness and the readiness of the medical providers. Then to determine the adequacy of the civilian healthcare facilities and providers to support the healthcare needs the service members and other beneficiaries through purchase care, purchase care being outside of the MTF. And then the last criterion that Congress wanted to see was the cost effectiveness of direct care services at the MTFs relative to purchase care in the area. The bottom line it may help the listeners to understand the bottom line of the plan was that DoD reviewed 77 MTFs in the United States, the plan included decreasing capabilities at 43. Shifting that care out to purchase care, and then closing five of those MTFs it’s quite complex, as we’ve said.
Tom Temin: And I guess my overall sense in looking and skimming at this report is that God made those decisions with not enough of the proper information it should have had going into the variable.
Brenda Farrell: Yes, they did a very thorough job documenting their methodology that guided the approach and incorporating the cross cutting statutory elements. But we found that often they used incomplete or inaccurate information, sometimes both, where there were gaps. Especially of concern is the first criterion on military medical readiness, because as a first step, this being the highest priority, DoD decided on a strategy They believe what prioritize each MTF support to service members medical readiness and the readiness of the medical providers. DoD you determined that MTFs should maintain certain minimum capabilities for service members, including primary care, and on a case by case basis, some specialties such as behavioral health, physical therapy, sometimes if there’s a training component on an installation, it might be urgent or emergency care, and then DoD also evaluated each MTFs contribution toward clinical readiness of the providers. They looked at workload or graduate medical education, but we found that DoD conducted limited MTF readiness support for military primary care and non physician medical providers. And who am I talking about, their focus was more on casually combat providers, the physicians rather than The other physicians needed for primary care, nurses and listed medical and surgical specialties. So they only looked at a small portion of the medical workforce that is needed for all military medical readiness. And you’re probably going to ask, well why did they do that? They did that because they didn’t have metrics for all the categories. They had the metrics for the combat casualty care providers, but they didn’t have the metrics for those other categories. They did look at productivity goals for primary physicians, but productivity goals aren’t the same as metrics because they don’t identify the type of service needed at the MTF. So for their for the highest priority, there’s still a huge gap in terms of the medical workforce that would be needed to help ensure the military medical readiness of service members and the providers.
Tom Temin: Now, you said that GAO had to pass muster on the plans before they proceeded, did I hear that correctly? And so what is the status of the reorganization and the restructuring at this point?
Brenda Farrell: Well, we offered our findings and recommendations to Congress. Now it’s up to Congress if they want to take some kind of action for DoD. And as you know, the Senate Armed Services Committee is getting ready to go to marks so it’d be interesting to see what they may reflect and their version of the NDAA. They could do nothing. They could take a wait and see attitude. We don’t know. DoD has put a pause on this particular reform along with some of their other reforms because of what’s been going on with COVID-19. But the pause ends at the end of June, so we’ll have to see if they continue to put a pause or if they move forward with the restructuring or if Congress take some action, perhaps based on GAOs findings and recommendations.
Tom Temin: Yeah. So to summarize the findings and recommendations, basically they need to do more research and they need to refine their information on which they’re basing decisions about the MTFs. And do they generally concur with what you have recommended?
Brenda Farrell: Yes, they did. And we had other recommendations that dealt with the adequacy of nearby healthcare, where the second criterion was to determine if the MDS for restructuring had adequate civilian healthcare facilities and providers in proximity. And we actually had three areas where we found some incomplete and inaccurate information. One dealing with the quality of the providers with missing information. The second was the number of available civilian providers was questionable, we thought it might be understated. And then the third one dealt with the standardized time that DoD sets for a patient to drive to their provider. There were six, DoD concurred with two of those pretty well. The others they partially concurred. So those are the ones we want to watch very carefully, because we believe that all of the recommendations need to be fully implemented.
Tom Temin: It strikes me that what they’re doing is somewhat, not totally, but somewhat analogous to what the VA has been trying to do in increasing the choice program. Is there anything that DoD can learn from what VA has gone through, maybe vice versa?
Brenda Farrell: We didn’t compare the restructuring to VA. We did when we would find missing information, we would see if that information was even available. So we we don’t want to recommend, for example, that they assess the quality of civilian providers if that informations not there. But there is information on quality providers that the Centers for Medicare and Medicaid along with some private insurers developed metrics for quality of specialty care. And that’s something that is available, we cite it in the report. And there’s other sources as well. So we believe that there’s for each of the findings that we raise about problems, we do have examples of where that information might exist or how it could be improved without taking, you know, another 10 years.
Tom Temin: So the day of real reckoning is yet to come, isn’t it?
Brenda Farrell: Yes, it is. They have until October 1, 2025 to complete the restructuring. So we believe that they do have some time to go in and fine tune some of these areas that we believe are missing information or not quite accurate.
Tom Temin: Brenda Farrell is director of defense capabilities and management issues at the GAO. Thanks so much.