Defense Health Care: Department of Defense Needs a Strategic Approach to Contracting for Health Care Professionals
Published: 2013-05-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: DOD operates a large and complex health care system that employs more than 150,000 military, civilian, and contract personnel working in military treatment facilities. Each military department operates its own facilities, and contracts separately for health care professionals to supplement care provided within these facilities. In fiscal year 2011, these contracts totaled $1.14 billion.
In the National Defense Authorization Act for Fiscal Year 2012, Congress mandated that GAO review the military departments' acquisition of health care professional services. This report examines (1) the contracting practices used by the departments and their cost effectiveness; (2) the extent to which the departments consolidate health care staffing requirements; (3) the percentage and associated costs of contract health care professionals working at on-base facilities versus offbase; (4) the training requirements for and experience of medical services contracting personnel; and (5) the extent to which the departments' policies address legislated quality standards for contract civilian health care professionals and for staffing companies that provide these professionals. To conduct this review, GAO reviewed military health care policies, analyzed DOD's fiscal year 2011 procurement and staffing data, and interviewed DOD military health system officials.
section_title: What GAO Found
paragraphs: The military departments--the Army, Navy, and Air Force--generally use competition and fixed-price contracts when contracting for medical professionals. These practices can provide lower prices or reduced risk for the government. The military departments use a number of contract arrangements, including contracts awarded to multiple health care staffing companies, for health care professionals. Military department analyses indicate that multiple-award contracts result in lower prices compared to other contract arrangements.
The Department of Defense (DOD) does not have a consolidated agency-wide acquisition strategy for medical services. In the absence of such a strategy, contracting for health care professionals is largely fragmented. For example, the military departments had not consolidated their staffing requirements by developing joint contracts beyond a limited number of instances amounting to about 8 percent of the fiscal year 2011 spending on health care professionals. The departments have made efforts to use multiple-award contracts to consolidate intraservice staffing requirements, but GAO identified several instances where multiple task orders were placed for the same type of provider in the same area or facility. A more consolidated strategic sourcing strategy could allow DOD to acquire medical services in a more cost-effective way.
Nearly all of the military departments' 11,253 contract health care professionals--96 percent--worked in 114 on-base military treatment facilities in fiscal year 2011, while the remaining 4 percent worked in 8 off-base clinics. The costs associated with the contracted health care services provided at on-base facilities are not comparable to such costs at off-base facilities for a variety of reasons. For example, some Military Health System cost accounting data have been characterized as unreliable. In addition, according to DOD officials, labor categories, labor costs, and full time equivalent calculations all vary by military department and in some cases by facility, contract, or geographic location, making a cost comparison problematic.
DOD medical services contracting personnel are subject to DOD-wide training requirements. Consistent with DOD-wide training for all its contracting officers, DOD does not require health care contracting officers to have specialized training or experience. The required training provides a foundation for career field knowledge and is not targeted to specific types of acquisitions, including contracts for health care professionals. Health care experience among contracting personnel varied by location. Air Force contracting officers are not typically dedicated to medical services contracting, unlike their counterparts in the Army and Navy. The military departments provide contracting officers' representatives, who provide contract oversight, with specialized training in contracting for health care.
GAO found that each of the departments has policies or procedures in place that generally address most of the legislated quality standards enacted in 2007 for contract health care professionals and the staffing companies that provide them. However, DOD did not require the military departments to use consistent quality standards in response to this legislation because DOD officials believed that the departments were already applying these standards as part of their contracting processes.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Secretary of Defense develop a DOD-wide strategic approach to contracting for health care professionals. DOD concurred with the recommendation.

section_title: Letter
paragraphs: The Department of Defense (DOD) operates a large and complex health  care system that employs more than 150,000 military, civilian, and  contract personnel working in military hospitals and clinics, commonly  referred to as military treatment facilities (MTF). DOD’s fiscal year 2014  budget request for health care is almost $50 billion, and is projected to  increase substantially in the next few years. Historical rates of cost growth  in DOD’s Military Health System have been significantly higher than the  corresponding rates in the national economy. Within DOD, each of the  military departments—Army, Navy, and Air Force—operates its own  MTFs, and generally contracts separately for health care professionals to  supplement care provided within these facilities. As health care consumes  an increasingly large portion of the defense budget, DOD leadership has  recognized the need to reduce duplication and overhead, and operate the  most efficient health system possible. In addition, DOD must balance the  challenges posed by maintaining a health care system that meets the  military’s readiness needs while also making changes in its business and  health care practices to control costs and improve effectiveness.
Section 726 of the National Defense Authorization Act for Fiscal Year  2012 (NDAA for FY 2012) directed us to review the contracting activities  of the military departments with respect to providing health care  professional services to members of the armed forces, dependents, and  retirees. This report (1) describes the contracting practices used by the  military departments to provide health care professional services and  what is known about the cost effectiveness of these practices, (2)  assesses the extent to which the military departments have consolidated  their health care staffing requirements, (3) identifies the percentage of  contract health care professionals at on-base and off-base facilities and  discusses the extent to which the costs associated with care provided by  these professionals can be compared, (4) describes the training  requirements and experience of medical services contracting personnel,  and (5) identifies the extent to which the military departments have  policies or procedures that address legislated quality standards for  contract health care professionals and for the staffing companies that  provide them.
To address contracting practices, we analyzed data obtained from the  Federal Procurement Data System-Next Generation (FPDS-NG) on  medical services contracts funded in fiscal year 2011, the latest year for  which complete data were available when we began our review. We  analyzed DOD’s contract spending for medical services based on three  different factors– whether the contracts were awarded competitively, the  pricing terms, and the contract arrangement. We also reviewed past  reports by DOD, GAO, and others. To assess the consolidation of health  care staffing requirements, we obtained data from the military  departments on the number and dollar value of contracts for health care  professionals. To determine on-base and off-base percentages of health  care professionals, we obtained and reviewed data from the military  departments on the type, number of, and obligations associated with  contract health care professionals at all on-base MTFs and associated  off-base clinics in fiscal year 2011, the latest year for which complete data  were available when we began our audit work. We also discussed with  knowledgeable officials the relevant data DOD maintains on costs  associated with on-base and off-base facilities and potential cost  comparison approaches and associated limitations. To describe contract  training requirements and experience, we reviewed DOD-wide and  military department-specific policies and requirements for contracting  personnel. We also obtained information on the training and experience  of contracting personnel at facilities with small and large numbers of  contract health care professionals. To address quality standards, we  reviewed federal regulations, DOD and military department-level policies  and procedures, and standard contract provisions, as provided by the  military departments. We reviewed this documentation to assess whether  each of the military departments generally addressed specific legislated  quality standards outlined in section 732 of the National Defense  Authorization Act for Fiscal Year 2007 (NDAA for FY 2007).
To address all objectives, we interviewed and obtained documentation,  including contract data, from officials at 11 MTFs and the following  organizations:
Army Health Care Acquisition Activity,
Navy Medical Logistics Command,
Air Force Medical Service,
Joint Task Force National Capital Region Medical Command (JTF  CapMed), and
DOD’s TRICARE Management Activity (TMA).
We assessed the reliability of these data by interviewing officials from the  military departments and testing the data for any obvious errors. We  determined that the data were sufficiently reliable for the purposes of our  review. See appendix I for additional details on our scope and  methodology.
We conducted this performance audit from July 2012 to May 2013 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: DOD’s Military Health System
paragraphs: DOD’s Military Health System has two missions: supporting wartime and  other deployments, and providing peacetime health care. In fiscal year  2011, DOD offered health care services to about 9.7 million eligible  beneficiaries in the United States and abroad through TRICARE, the  Military Health System’s regionally structured health care program.  Under TRICARE, beneficiaries may obtain care either through DOD’s  direct care system of MTFs, or through DOD’s purchased care system of  civilian providers. The total DOD health care budget for fiscal year 2011  was $52.45 billion, of which $17.76 billion was to provide health care  through the direct care system of MTFs. Of the $17.76 billion in direct  care costs, DOD spent about $1.91 billion contracting for various medical  services, including about $1.14 billion for contract health care  professionals, the primary focus of this report. Figure 1 below shows the  total DOD health care budget, the amount spent on direct health care,  and the amount the military departments spent on contracts for health  care professionals working in MTFs in the United States in fiscal year  2011.
The Assistant Secretary of Defense for Health Affairs (Health Affairs) is  the principal advisor for all DOD health policies and programs. This office  issues policies, procedures, and standards that govern the management  of DOD medical programs and has the authority to issue DOD  instructions, publications, and memorandums that implement policy  approved by the Secretary of Defense or the Under Secretary of Defense  for Personnel and Readiness. However, this office does not have direct  command and control of the military departments’ MTFs. TMA, under the  authority and direction of Health Affairs, is responsible for awarding,  administering, and managing DOD’s contracts for purchased care,  including the regional managed care support contracts. See figure 2 for  the current organizational structure of DOD’s Military Health System.
Under the direct care system, each military department recruits, trains,  and funds its own medical personnel to administer medical programs and  provide medical services to beneficiaries. The Departments of the Army  and the Navy each has a medical command, headed by a surgeon  general, who manages each department’s MTFs and other activities  through a regional command structure. Within these medical commands,  the Army and Navy have separate but similarly centralized approaches to  contracting for medical services, including health care professionals. The  Army acquires medical services through the Health Care Acquisition  Activity, which has a main contracting center and five regional contracting  offices. The Naval Medical Logistics Command is in charge of providing  contracting support for medical services for both the Navy and the Marine  Corps. Though similar in his role as medical advisor to the Air Force Chief  of Staff, the Air Force Surgeon General exercises no command authority  over Air Force MTFs. The Air Force does not have a medical contracting  command like the other two services. Instead, the Air Force has a  decentralized contracting structure and relies on more than 60 separate  local base contracting offices to acquire medical services.
An additional medical organizational structure—JTF CapMed—was  established in 2007 to manage MTFs within the National Capital Region  and to execute actions required under the Base Realignment and Closure  (BRAC) process. JTF CapMed is responsible for the management of the  Walter Reed National Military Medical Center in Bethesda, Maryland,  which was created by combining Walter Reed Army Medical Center and  the National Naval Medical Center; and Ft. Belvoir Community Hospital,  which replaced DeWitt Army Community Hospital at Ft. Belvoir, Virginia.  JTF CapMed relies on the Army to award contracts for health care  professionals because it does not have its own contracting authority.
Figure 3 depicts the size and location of MTFs in the United States.
A variety of contracting arrangements are available to DOD to contract for  health care professionals. These contracting arrangements are subject to  the Federal Acquisition Regulation (FAR)—the primary regulation for use  by all federal executive agencies in their acquisition of goods and  services. Table 1 lists some of the different contracting arrangements  used to contract for health care professionals, including multiple-award  contracts.
The military departments contract for many different types of health care  professionals. For example, they often contract for nurses, family practice  doctors, and medical assistants, among others.
The typical process for contracting for these types of professionals is as  follows:
Once it has been determined that a staffing requirement needs to be  fulfilled through a contractual agreement, the acquisition strategy is  developed. The strategy addresses the type of contracting  arrangement that should be used, the payment terms to use, and the  competition requirements.
A contracting officer—who is a federal employee with the authority to  enter into, administer, and/or terminate contracts—awards a contract.
A contracting officer’s representative (COR) is assigned to oversee  the contract and ensure that the contractor is performing in  accordance with the standards and terms that are set forth in the  contract. If problems with a contractor’s performance arise, the COR  serves as the contract focal point between the contracting officer and  contractor.
section_title: DOD Generally Uses Competition, Fixed Prices, and Multiple- Award Contracts When Acquiring Medical Services
paragraphs: All three military departments used competition and fixed-price contracts  for a majority of their medical services contract obligations in fiscal year  2011. Together, the three military departments most often use multiple- award contracts to contract for health care professionals. Military  department analyses indicate that multiple-award contracts may result in  lower costs compared to some other contract arrangements. In addition,  the military departments use other contract arrangements, such as clinical  support agreements (CSA) to fill requirements in a remote location or for  a particular health care specialist.
subsections: section_title: The Military Departments Use Competitively Awarded Fixed-Price Contracts for Medical Services
paragraphs: The military departments obligated $1.91 billion for medical services in  fiscal year 2011.This figure includes $1.14 billion for contract health care  professionals as well as other medical services contract obligations within  and outside of MTFs worldwide. Of the $1.91 billion, the military  departments used competition for approximately 75 percent of obligations  when contracting for medical services. Federal regulations generally  require the use of full and open competition, which can help to reduce  costs. We have previously reported that competition is a critical tool for  achieving the best value. Table 2 shows the percentage of each military  department’s direct health care medical services obligations that were  competed in fiscal year 2011.
We also found that fixed-price contracts were used for more than 90  percent of direct health care medical service obligations in fiscal year  2011, as shown in table 3. Generally, under a fixed-price contract for  services, the government pays a certain amount for the services  specified. We previously have reported that this type of contract  generally results in the least amount of risk to the government.
We found that the Army, Navy, Air Force, and JTF CapMed together used  multiple-award contracts for 64 percent of the $1.14 billion in obligations  for contracts for health care professionals in fiscal year 2011. CSAs  accounted for only 3 percent of the obligations spent on health care  professionals in the same time period. Figure 4 shows the percentage of  fiscal year 2011 obligations for health care professionals by contract  arrangement.
Because multiple-award contracts are competitive, they avail the military  departments of one of the most fundamental and cost effective tools in  contracting. Competition is the cornerstone of a sound acquisition  process and a critical tool for achieving the best return on investment for  taxpayers. Officials from the military departments told us that they use  multiple-award contracts for many reasons. In addition to perceived cost  effectiveness, officials stated that multiple-award contracts result in  shorter acquisition lead times and reduce the risk of bid protests.  Officials also stated they use multiple-award contracts because these  contracts are awarded to small businesses, which helps the military  departments meet their small business contracting goals. In fact, 100  percent of the current Army, Navy, and Air Force multiple-award contracts  are awarded to small businesses. DOD officials also stated that multiple- award contracts have facilitated the streamlining of acquisitions and the  standardization of contract requirements, which saves time and contract  administration costs.
During our review, Navy and Air Force officials completed analyses of  their contracting arrangements which indicated that multiple-award  contracts may result in lower costs when contracting for health care  professionals compared to CSAs. Specifically, Navy officials conducted  an analysis comparing the hourly costs associated with the same type of  health care professional for each of three different contract  arrangements—multiple-award contracts, individual set-aside (ISA)  contracts, and CSAs. Based on this analysis, the Navy determined that  the hourly rate of providers contracted via CSAs was higher than under  multiple-award contracts for the same types of services. Similarly, Air  Force officials told us and provided analysis indicating that CSAs cost  more than multiple-award contracts. In addition, the Air Force conducted  a separate analysis to determine cost savings on their multiple-award  contracts. Based on this analysis, an Air Force official stated that they  have realized $13.8 million, or 15 percent, in savings on their current  multiple-award contracts—which took effect in December 2011— compared to their previous multiple-award contracts.
section_title: The Military Departments Also Use Other Contracting Arrangements in Contracting for Services for Health Care Professionals
paragraphs: Each military department has the flexibility to employ a variety of other  contract arrangements to meet its needs for health care professionals.  For example, Navy officials stated they sometimes contract directly with  an individual health care professional using an ISA when an individual’s  qualifications will be used as the primary selection criterion and cost of  the contract is not as important as the provider’s qualifications. Navy  officials stated they also use ISAs because they are more likely to be able  to pay a health care specialist a competitive market-based salary if they  contract with the provider directly instead of contracting with a staffing  company that typically adds 15-20 percent in overhead costs. A DOD  Inspector General report stated that ISAs may be appropriate in certain  circumstances, such as acquiring a scarce specialty. One drawback of  using an ISA is the amount of time it takes to award a contract. According  to Navy officials, it can take 9-12 months for a contract to be awarded. If  the health care professional on the contract decides to leave, the military  departments are left with an unfulfilled requirement while a new contract  is developed, solicited, and awarded.
A CSA is another contracting arrangement that can be used to acquire  health care professionals. Similar to ISAs, CSAs are often used to  contract for hard-to-fill positions for health care specialists, especially in  remote locations. Although the Navy used CSAs in the past to fill  requirements for health care professionals, Navy officials stated that they  currently do not use CSAs because this contract arrangement is less cost  effective and provides for less competition. Although CSAs were reported  by the military departments to be more expensive than multiple-award  contracts, TMA officials stated that they have been used to fill positions  when other contracting arrangements have been unsuccessful.
Regardless of the contract arrangement, some DOD officials told us that it  is challenging to fill the requirements for many of the highly skilled health  care professionals they need to work at MTFs. For instance, in 2012,  multiple-award contracts were competitively awarded to staffing  companies specifically for the National Capital Region. Some of the task  orders on these multiple-award contracts had to be terminated when the  staffing companies could not recruit incumbent health care professionals  whose previous salaries had been well above prevailing market rates.  This resulted in insufficient time for them to recruit new employees and  complete the hiring process without causing gaps in service. Air Force  officials also experienced similar challenges in their implementation of  multiple-award contracts. For example, some of their multiple-award task  orders were terminated because the staffing companies were unable to fill  the requirements based on the contracted prices they had proposed.
section_title: Consolidation of Staffing Requirements Is Limited in the Absence of a DOD- wide Acquisition Strategy
paragraphs: Contracting for health care staffing requirements across the military  departments remains largely fragmented. In the absence of an agency- wide strategy, the military departments have attempted to consolidate  some staffing requirements, but these efforts have been limited. Over the  last 9 years, various DOD groups as well as GAO have recommended  that DOD take steps toward such a strategy, but DOD still does not have  an agency-wide acquisition strategy to consolidate these requirements.
subsections: section_title: Despite Previous Recommendations, DOD Does Not Yet Have a Strategic Approach to Acquiring Medical Services
paragraphs: Studies and reports by GAO and others have identified challenges with  the fragmented approach that the military departments take to contract for  medical services. For example, in 2004, a DOD Inspector General report  found that the Military Health System could better coordinate contracting  efforts and reduce duplication and fragmentation among DOD contracting  organizations that acquire medical services. The report called for a joint  and strategic enterprise approach to medical services acquisition.
In 2005, a DOD-wide council convened by the Assistant Secretary of  Defense for Health Affairs recommended that DOD identify an alternative  to the existing approach for acquiring direct care medical services, and  suggested the need for a joint process and joint contracting centers  responsible for the coordination, development, and contract execution of  medical services acquisitions. This council also recommended that DOD  establish strategic sourcing councils to develop strategies for sourcing  key labor categories, including nurses and radiologists, and collect  standardized aggregate procurement data across military departments.  Strategic sourcing involves a shift away from numerous individual  procurements to a broader aggregate approach, and often results in cost  savings. Our prior work found that success in this regard requires the  commitment of senior management, as well as reliable and detailed  agency-wide spending data to identify opportunities to leverage buying  power, reduce costs, and better manage suppliers.
In 2007, DOD drafted a charter for a Defense Medical Strategic Sourcing  Council. The council’s charter stated that its goals were to allow DOD to  standardize the professional services acquisition process, further  decrease variation in unit cost for services, and reduce acquisition  workload. However, according to a TMA official, the military departments  never signed the charter, and the council was never convened.
GAO reported in July 2010 that DOD would benefit from enhanced  collaboration among the military departments in their processes for  determining professional medical services requirements and  recommended that DOD identify, develop, and implement joint medical  personnel standards for shared services. While DOD concurred with our  recommendation, as of March 2013, no action has been taken to address  it. In our March 2011 report on opportunities to reduce duplication,  overlap, and fragmentation in government programs, we noted that  consolidating common administrative, management and clinical functions  within the Military Health System could increase efficiencies and  significantly reduce costs, but that DOD had taken only limited actions in  this area.
In June 2011, the Deputy Secretary of Defense established a Task Force  to review various options for changes to the overall governance structure  of the Military Health System and of its multi-service medical markets.  The Task Force identified 13 potential governance options for the Military  Health System. DOD selected an option for Military Health System  governance that would create a defense health agency in part to assume  the responsibility for creating and managing shared services, and leave  the military chain of command intact with the military departments in  control of their military treatment facilities. This option would include a  shared services concept to consolidate common services, including  acquisition, under the control of a single entity. The Deputy Secretary of  Defense stated in a March 2012 memo that DOD recognizes that there  are opportunities to achieve savings in the Military Health System through  the consolidation and standardization of many shared services, including  but not limited to pharmacy programs, medical education and training,  health information technology, budget and resource management, and  acquisitions.
While DOD is moving forward incrementally with its plans to transform the  Military Health System structure and set up the defense health agency,  decisions about the consolidation of health care staffing requirements  remain outstanding. For example, DOD established a medical services  contracting subworking group in 2012. According to DOD officials, the  group is in the process of examining issues related to medical services  acquisition and anticipates briefing out its recommended courses of  action within DOD in the July 2013 time frame. Its potential  recommendations include three different approaches to realigning and  potentially consolidating the responsibility for medical services  acquisitions within DOD. Additionally, in the National Defense  Authorization Act for Fiscal Year 2013, Congress included a requirement  for DOD to provide an implementation plan for its governance reforms,  including goals, timeframes, and estimated savings, among other things.
section_title: In the Absence of a DOD- wide Strategy, Consolidation of Staffing Requirements Has Been Limited
paragraphs: In the absence of an agency-wide approach for medical services  acquisition, there have been only limited instances of the consolidation of  health care staffing requirements. Some of these instances have involved  efforts across the military departments. For example, the joint contracts  that were reported to us accounted for approximately 8 percent of the  $1.14 billion in obligations for health care professionals in fiscal year  2011. Other efforts have involved actions within the departments. For  example, the departments have made efforts to use multiple-award  contracts to consolidate intraservice staffing requirements, but we  identified several instances where multiple task orders were placed for  the same type of provider in the same area or facility.
The military departments have consolidated a limited number of staffing  requirements by developing contracts used at joint facilities such as those  in San Antonio and the National Capital Region. All told, the joint  contracts that were reported to us make up approximately 8 percent of  the $1.14 billion in obligations for health care professionals in fiscal year  2011. In 2009, the Army established two contracts for nurses to work at  the San Antonio Military Medical Center, which operates as a joint facility  for the Army and the Air Force. Army officials explained that, prior to this  joint effort, there were more than 12 contracts with nursing requirements  between Brooke Army Medical Center and the Air Force’s Wilford Hall  Medical Center, both in San Antonio. The multiple contracts created  competition between the two military departments’ facilities for nursing  staff. Because of the BRAC-related realignment of medical services in  San Antonio, the Army was able to consolidate the nursing requirements  and use one multiple-award contract for registered nurses and one for  licensed vocational nurses to provide nursing services at both facilities.  According to Army officials, these contracts are more successful than the  previous contracts in placing the necessary number of nurses in the  MTFs in San Antonio, and less administrative oversight is needed.
In the National Capital Region, the Army had multiple-award contracts for  health care professionals that were awarded prior to the transfer of  control to JTF CapMed. The Army then began to award contracts for JTF  CapMed facilities in 2012. These contracts are considered to be joint  because these facilities are used by more than one military department as  a result of the BRAC process. According to an Army analysis, these  contracts resulted in a 14 percent savings over the previous set of  contracts for health care professionals at the Walter Reed National  Military Medical Center in Bethesda.
The Navy also used multiple-award contracts for health care  professionals for MTFs in the National Capital Region that were awarded  prior to the transfer of control to JTF CapMed at the end of fiscal year  2011. Other than the contracts that were in place for these MTFs before  August 2011, the Navy stated that it did not have any additional contracts  that were used by other military departments. The Air Force stated that it  has not awarded any contracts with jointly developed requirements, but  Air Force multiple-award contracts are open to use by other military  departments to support joint MTFs.
While examples of joint contracting efforts in place during fiscal year 2011  were limited, additional contracts available to more than one military  department have been awarded since then, or are planned. For  example, seven joint medical service contracting initiatives were planned  by the Army, including a new contract for medical services in Europe that  would be available to all three military departments. None of these has  been awarded as of February 2013.
The military departments have made efforts to consolidate some staffing  requirements within their own MTFs using multiple-award contracts.  Currently, multiple-award contracts in the Army and Navy are generally  set up by U.S. geographical region and by provider type to meet the  requirements of more than one facility. For example, in each geographical  region, the Army and the Navy each have multiple-award contracts for  nurses, and one in each region for doctors. In 2012, the Navy had 6  multiple-award contracts on the west coast and 5 on the east coast,  including many types of health care professionals. The Navy routinely  receives 25 to 40 proposals, and usually makes 3 to 6 awards to health  care staffing companies. Navy officials told us that before multiple-award  contract use was prevalent, buying activity was more fragmented. More  individual contracts—for specific labor categories and locations—made  the burden much greater in terms of administration and oversight.  Officials explained that, at one point, the organization responsible for  medical services acquisitions was funded on the basis of how many  contracts were awarded, which incentivized inefficiency.
In contrast, the Air Force uses multiple-award contracts that are set up  nationally to be used by all of its MTFs, and these contracts also include  many types of health care professionals. The Army awarded national  contracts for health care professionals in fiscal year 2003, but officials  said this approach was unsuccessful because not enough companies  were able to compete for those contracts and provide health care staffing  services on a national scale. Market research and feedback from  contractors indicated that regional multiple-award contracts would allow  greater opportunities for more small businesses to compete. The Army  subsequently put in place multiple-award contracts with regional  requirements for particular categories of health care professionals, such  as nurses. The Army found that this approach led to more successful  outcomes.
Despite the use of multiple-award contracts, the potential for more  consolidation among task orders remains. We identified several instances  where many task orders were placed for the same type of provider in the  same area or facility, such as 24 task orders in fiscal year 2011 for  medical assistants, 16 separate task orders for Licensed Practical  Nurses, 8 for clinical psychologists and 6 for family practitioners, all at the  same MTF.
section_title: Almost All Contract Health Care Professionals Work in On-Base Military Treatment Facilities
paragraphs: Nearly all of the military departments’ contract health care professionals— 96 percent—worked in facilities located on military installations in fiscal  year 2011. The costs associated with these contracted health care  services provided at on-base facilities are not comparable to off-base  facilities for a variety of reasons. For example, significant issues have  been identified within the Military Health System cost accounting system  that affect the calculation of unit costs. Further, based on available data  and interviews with DOD officials, we determined that labor categories,  labor costs, and full-time equivalent calculations all vary by military  department, and in some cases by facility or contract. In addition,  according to Navy officials, market-based salaries for the same type of  provider can vary by geographic location.
subsections: section_title: Most Direct Care by Contract Health Care Professionals Is Provided at Facilities Located on Military Installations
paragraphs: DOD reported information on 114 primary on-base MTFs in the United  States with contracted health care professionals. In addition, the military  departments identified 8 off-base facilities with contracted health care  professionals. Collectively, the Army, Navy, Air Force, and JTF CapMed  had 11,253 full-time equivalent (FTE) contract health care professionals  within the United States in fiscal year 2011, 96 percent of whom provided  care at on-base facilities. Figure 5 shows the number of contract health  care professionals, civilian health care professionals, and active duty  military health care professionals in fiscal year 2011, by military  department and JTF CapMed.
Table 4 provides information on the number of contracted FTEs at both  on-base and off-base facilities. For a complete list of the MTFs and  contract health care professional FTEs reported to us by the military  departments, see appendix III.
The Army reported that all contract health care professionals worked  in 28 primary on-base MTFs. The Army did not report any off-base  facilities with contract health care professionals.
The Navy reported 21 on-base primary MTFs. Four percent of its  contract health care professionals worked in one of four off-base  clinics.
The Air Force reported 63 on-base primary MTFs. Less than 1  percent of its contract health care professionals worked in one  reported off-base clinic associated with the MTF at MacDill Air Force  Base as well as one primary MTF, Buckley, which is located off-base.
Hospital in 2011. Twenty-three percent of contract health care  professionals in the National Capital Region worked in one of two off- base clinics, the Fairfax Health Center and the Dumfries Health  Center.
section_title: Costs Associated with Contract Health Care Professionals at On-Base Facilities Are Not Comparable to Those at Off-Base Facilities
paragraphs: Based on available data and interviews with DOD officials, we determined  that the costs associated with the provision of care by contract health  care professionals at on-base facilities and off-base facilities were not  directly comparable for a variety of reasons. First, DOD does not collect  and maintain standardized data on health care professionals that would  allow for comparisons of the cost of facilities across the military  departments, or even within a military department from one facility to  another. For example, labor categories are not standardized across DOD.  Labor costs, including salary, benefits, overtime, and other costs vary by  military department and by contract, and the definition of an FTE  employee varies by military department. Second, DOD’s Task Force  report on the Future of Military Health Care concluded that there were  significant issues with the Military Health System cost accounting that  affect the correct calculation of unit costs. For example, reported  workload data have been characterized as unreliable. DOD and military  department officials we spoke with confirmed this assessment during our  review. Third, the financial and data systems used by MTFs are not set  up to differentiate between the cost of care provided by contract health  care professionals versus the cost of care provided by civilian and active  duty health care professionals. Finally, market-based salaries for health  care professionals vary by geographic location and by specialty. For  example, the salary for a chiropractor in Washington, D.C. is significantly  higher than the salary for a chiropractor in the Portsmouth, Virginia area.  Therefore, comparing the costs associated with contract health care  professionals at off-base facilities to any contract health care  professionals at on-base facilities that were not working in the same  geographic area would not result in an appropriate comparison.
section_title: DOD Has Agency- wide Training Requirements for Contracting Personnel, and Health Care Experience Varies
paragraphs: DOD medical services contracting personnel are subject to DOD-wide  training requirements, and health care experience varies for these  personnel. The military departments provide CORs, but usually not  contracting officers, with specialized training in contracting for health care  professionals in addition to DOD’s requirements. The training provided to  contracting officers is generally not targeted to any specific area of  acquisition, including health care.
subsections: section_title: Contracting Officers Are Subject to DOD-wide Certification Requirements
paragraphs: Contracting officers are federal employees with the authority to bind the  government by signing a contract. Contracting officers across DOD are  subject to the Defense Acquisition Workforce Improvement Act (DAWIA)  requirements, which specify mandatory acquisition training and  experience standards for DOD’s acquisition workforce. DOD requires all  contracting officers to meet the same DAWIA requirements, regardless of  any specialization. The training offered by the Defense Acquisition  University (DAU) provides a foundation for acquisition and career field  knowledge, and is not targeted to specific jobs, including the award and  administration of contracts for health care professionals. In this regard,  contracting officers responsible for awarding and administering contracts  for health care professionals are no different than DOD contracting  officers working in other areas.
In addition to DOD-wide requirements, contracting officers responsible for  contracts for health care professionals generally have access to health  care-specific acquisition expertise within their organizations, according to  officials from the Army and Navy. For example:
Contracting officers at Army’s Health Care Acquisition Activity work  with the Medical Services Portfolio Manager, who serves as a  resource for both health care and acquisition expertise and assists in  the development of performance work statements and source  selection.
Navy contracting officers gain knowledge on the job through  collocation at the Navy Medical Logistics Command with experienced  contracting officers and program analysts with health care specialties.
The Army and Navy medical commands both have contracting officers  with primary responsibilities related to the award and administration of  contracts for health care professionals. The Army contracting officers we  spoke with at the San Antonio Military Medical Center each reported  having worked in medical contracting for over 8 years, awarding hundreds  of contracts for health care professionals. Similarly, a Navy official  provided documents showing that most Navy contracting officers  responsible for contracts for health care professionals each has at least 3  years of experience in medical contracting.
The Air Force relies on base contracting offices to support contracting for  health care professionals at its 63 MTFs and, in contrast to both the Army  and Navy, most Air Force contracting officers responsible for awarding  and administering contracts for health care professionals are also  responsible for the acquisition of non-medical products and services. As a  result, according to Air Force officials we spoke with, Air Force acquisition  professionals involved in medical services require additional training in  the use of an approach often used in this area, personal services  contracting, which is characterized by the employer-employee  relationship it creates between the government and the contractor’s  personnel. These contracts, expressly or as administered, make the  contractor personnel appear to be, in effect, government employees.  Personal services contracts are generally prohibited; however, personal  services contracts for professional medical services for DOD are  authorized by law.
Although all three services use personal services contracts to obtain  health care professionals, additional training in this area is not necessary  for the Army and Navy, according to a DAU official we spoke with, since  these departments’ contracting organizations have acquisition  professionals who frequently work with personal services contracts.  However, Air Force officials we spoke with reported that Air Force  contracting personnel would benefit from increased attention to personal  services contracting in the health care context, because, unlike most  government contractors, health care professionals are subject to the  direction and supervision of the government.
section_title: Required and Supplemental Training Provided to Contracting Officer’s Representatives
paragraphs: CORs are federal employees designated by the contracting officer to  perform certain contract administration duties. All CORs must meet  training and experience requirements specified in DOD’s Standard for  Certification of COR for Service Acquisitions issued in March 2010. This  standard defines DOD-wide minimum COR competencies, experience,  and training for three types of COR requirements, according to the  complexity of requirements and contract performance risk. Prior to  contract award, all CORs are required to take a basic 8-hour online  training course, provided through DAU. In addition to DOD-wide  requirements, contracting personnel we spoke with said CORs receive  contract-specific training from the appointing contracting officer. CORs  may also receive supplemental training provided by the military  departments in medical services contracting. Table 5 describes the type  of training provided to CORs by each military department.
Contracting oversight begins when the MTF nominates and the  contracting officer appoints CORs to monitor and report on contractor  performance. Importantly, CORs may not direct the work of the contractor  by making commitments or changes that affect price, quantity, quality,  delivery, or other terms and conditions of the contract. Within DOD’s  Military Health System, CORs oversee the performance of contract health  care professionals, including the review of contractor invoices and  documenting and reporting on the performance of health care  professionals to the contracting officer. The contract oversight model for  DOD’s Military Health System is different than typical DOD acquisitions,  because the military departments reported regularly using personal  services contracts when contracting for health care professionals who, as  described above, are subject to the direction and supervision by the  government. In contrast to typical DOD contracting oversight  arrangements, supervision of contract health care professionals is  typically accomplished by a government employee at the MTF. In these  instances, government supervisors, who are usually health care  providers, work with the COR as they oversee and report on the  performance of contract health care professionals.
The level of experience and type of responsibilities of CORs assigned to  medical services contracts varies by MTF location. CORs we spoke with  had responsibilities ranging from the oversight of only a few contract  health care professionals to more than 100 professionals. Further, some  CORs are full-time and dedicated solely to overseeing contracts for health  care professionals. For selected locations, we observed the following:
For the Army, a COR working at the San Antonio Military Medical  Center with a professional background as a budget analyst reported  that CORs in this location have backgrounds ranging from  administrative professionals to physicians. This COR was responsible  for other duties at the large facility in addition to overseeing the  performance of 130 FTE health care professionals. The COR for  personal services contracts at Fox Army Health Center, a health  systems specialist and former Army medic, was responsible for  additional duties as the Chief of Clinical Operations. The official had  12 years of experience as a COR on medical services contracts.
For the Navy, personnel assigned as CORs at the Portsmouth Naval  Medical Center and one of its branch clinics work on a full-time basis  overseeing approximately 100 health care professionals each. This  group’s experience ranged from members with less than 1 year to  those with over 20 years of experience. The COR at Navy’s Saratoga  Springs Branch Clinic was classified as a health systems specialist  and had over 20 years of experience as a COR. This COR was  located off-site and was responsible for other duties in addition to  overseeing approximately 30 task orders for health care  professionals.
For Air Force, the service contract manager at Wilford Hall  Ambulatory Surgical Clinic is the primary COR and government  supervisors are alternate CORs. However, this is an arrangement  that is unique to that facility, according to Air Force officials. The COR  for personal services contracts at Andersen Air Force Base reported  having worked in this capacity for about a year and a half and was  responsible for other duties related to medical logistics. Prior to  assignment as a COR at Andersen Air Force Base, this official had  over 4 years of experience in contract services at a large MTF.
section_title: The Military Departments’ Existing Policies and Procedures Generally Address Legislated Quality Standards, but DOD Did Not Require Consistency
paragraphs: Section 732 of the NDAA for FY 2007 directed the Secretary of Defense  to require consistent quality standards for contract health care  professionals and the staffing companies that provide them across all of  the military departments’ MTFs. According to DOD officials, DOD did not  require consistent quality standards or take any additional actions in  response to this legislation—such as by establishing a specific policy or  guidance—because officials believed the military departments were  already applying these standards as part of their contracting processes.  We found that each of the departments had policies or procedures in  place that generally address most of the NDAA for FY 2007 quality  standards.
subsections: section_title: DOD and the Military Departments Already Had Policies for the Credentialing and Privileging of Health Care Professionals and Are Taking Steps to Ensure Consistency
paragraphs: The NDAA for FY 2007 requires consistent credentialing requirements  among MTFs. Credentialing is the process of inspecting and  authenticating the documentation for appropriate education, training,  licensure, and experience for health care professionals. Privileging is the  corresponding process that defines the scope and limits of practice for a  health care professional based on their relevant training and experience,  current competence, peer recommendations, and the capabilities of the  facility where the health care professional is practicing. The Assistant  Secretary of Defense for Health Affairs is responsible for developing and  overseeing DOD’s credentialing and privileging requirements for health  care professionals to ensure consistent application across the Military  Health System. To implement DOD’s requirements, the military  departments’ surgeons general—who are delegated responsibility by the  secretaries of their respective departments—establish specific  credentialing and privileging requirements, which their MTFs are required  to follow.
In this review, we found that DOD and the military departments already  had policies and procedures in place for the credentialing and privileging  of health care professionals; however, these requirements are not yet  consistent across the military departments. We previously reported in  December 2011 that the military departments had established  requirements that were in some cases inconsistent with DOD’s  requirements and each other’s. In response, DOD and military  department officials reported taking steps to standardize the credentialing  and privileging processes across DOD. For example, the Navy took steps  to align its policy with DOD’s by changing its requirement for primary  source verification to apply to all provider licenses ever held instead of  just those licenses held in the past 10 years. Additionally, DOD and VA  formed a workgroup in July 2012—which also included officials from the  Army, Navy, Air Force, and JTF CapMed—in order to standardize the  credentialing and privileging processes across the military departments,  and eventually with VA, so that health care professionals could more  easily move between DOD and VA facilities. As part of this effort, the  workgroup was tasked with exploring the possibility of developing a joint  credentialing software system for use by both DOD and VA. A DOD  official told us that the workgroup expects to issue recommendations by  June 2013.
section_title: Military Departments Have Policies or Procedures That Generally Address the Standards for Staffing Companies
paragraphs: The NDAA for FY 2007 also requires consistent quality standards for the  staffing companies that provide contract health care professionals to the  MTFs, including, at a minimum, the Joint Commission’s Health Care  Staffing Services certification standards. The 2011 version of the Health  Care Staffing Services certification standards includes 23 standards that  cover four topic areas: (1) leadership, (2) human resources management,  (3) information management, and (4) performance measurement and  improvement. (See appendix IV for a list of these standards.)
We found that because DOD did not require the military departments to  use consistent quality standards for staffing companies as outlined in the  NDAA for FY 2007, the military departments did not have policies or  procedures in place for each of the Joint Commission’s Health Care  Staffing Services certification standards. However, each of them was  able to provide examples of regulations, policies, or military department- wide standardized contracting language that they thought addressed  many of these standards. The Air Force was able to provide similar  documentation for its centrally administered health care professional  contracts. The Air Force also was able to provide examples of regulations  and policies for its other health care professional contracts, which are  awarded and managed at the individual MTF level, but it could not  provide standardized language for these contracts.
We determined that, in most cases, the documentation provided by each  of the military departments generally addressed the individual Joint  Commission standards for staffing companies that provide health care  professionals. For example:
For the Joint Commission requirement that the staffing company have  a code of business ethics, each of the military departments provided  citations to federal regulations or standardized contract clauses that  required the staffing company to have an ethics code.
In some of these cases, the military departments addressed the individual  Joint Commission standards by providing policies or standardized  contract language that required the military departments to perform the  tasks themselves instead of expecting them to be addressed by the  staffing company. For example:
For the Joint Commission requirement that the staffing company  provide orientation to clinical staff, each of the military departments  cited standardized contract clauses that would require contract health  care professionals to participate in orientation and initial job training  provided by the MTF.
However, the documentation provided by the military departments did not  always appear to address certain Joint Commission standards. For  example:
For the Joint Commission requirement that the staffing company  clearly define its leadership roles, one of the military departments  cited standardized contract language that required the staffing  company to provide a point of contact, but did not address company  leadership roles.
In addition to the Joint Commission standards for staffing companies, the  NDAA for FY 2007 also requires additional standards covering financial  stability, medical management, continuity of operations, training,  employee retention, access to contractor data, and fraud prevention. We  found that each of the military departments provided documentation that  generally addressed the additional standards for staffing companies listed  in the NDAA for FY 2007. For example, each of the military departments  provided citations to federal regulations that addressed fraud prevention  for the staffing companies.
section_title: Conclusions
paragraphs: DOD has undertaken numerous studies concerning the governance of the  Military Health System. Performed by both internal and external boards,  commissions, task forces, and other entities, a number of these studies  recommended dramatic changes in the organizational structure of the  Military Health System, in part to address the fragmented approach that  the military departments take to contracting for professional medical  services. While the military departments generally agreed with the need  for improvements to their respective requirements determination  processes, fragmentation in requirements and contracting arrangements  persist because DOD has introduced change in its management and  oversight of the Military Health System in an incremental and limited  manner.
In the absence of a DOD-wide approach for the acquisition of medical  services, each military department continues to take a fragmented  approach to contracting for medical professionals without considering the  collective needs of the Military Health System. However, DOD is in the  process of revising the governance structure of the Military Health System  to centralize certain functions, such as acquisitions, that are fragmented  among the military departments. Consequently, now is a particularly  opportune time to revisit the need for a DOD-wide strategic sourcing  strategy with both near-term and long-term dimensions, including reliable  and detailed agency-wide data. Without such a strategy, the Military  Health System may be missing opportunities for acquiring professional  medical services in the most cost effective manner.
section_title: Recommendation for Executive Action
paragraphs: To achieve additional cost savings and efficiencies through increased use  of strategic sourcing, we are recommending that the Secretary of Defense  develop and implement a DOD-wide strategy to contract for health care  professionals. The strategy should identify specific responsible  organizations and timeframes, and should consist of both near-term and  long-term components:  In the near term, and to enable DOD to assess the efficacy and  impact of such a strategy, DOD should identify a category of health  care professionals or a multi-service market to pilot an approach to  consolidating health care staffing requirements.
Over the longer term, such a strategy should include an analysis of  medical services spending based on reliable and detailed agency- wide data, and should enable DOD to identify opportunities to  consolidate requirements and reduce costs.
section_title: Agency Comments
paragraphs: We provided a draft of this report to DOD for comment. In its written  comments, reproduced in appendix V, DOD concurred with our  recommendation. The department also agreed that it is at an opportune  time to revisit a Military Health System strategic sourcing strategy due to  the organizational transformation that is occurring in the stand-up of the  new Defense Health Agency. DOD stated that a Shared Services  Contracting subworking group will include this report and its  recommendations in their comprehensive review of contracting strategies,  governance, and processes. DOD anticipates that the subworking group  will present their final recommendations to senior leadership by August  2013. DOD also provided technical comments that were incorporated, as  appropriate.
We are sending copies of this report to the appropriate congressional  committees and the Secretary of Defense. In addition, the report is  available at no charge on GAO’s website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-4841 or woodsw@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix VI.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine what contracting practices are used by the military  departments to contract for medical services as well as what is known  about the cost effectiveness of these practices, we analyzed fiscal year  2011 data obtained from the Federal Procurement Data System-Next  Generation on medical service contracts to determine the extent to which  the military departments used particular contracting practices as well as  the types and amount of medical services that were purchased. We  obtained data on all contracts and task orders that were coded as medical  services and were active in fiscal year 2011 from the Federal  Procurement Data System-Next Generation, including information on  obligation value, contract payment type, a general description of the type  of service, and the extent of competition. To assess the reliability of the  data we looked for missing values and obvious errors and found the data  were sufficiently reliable for the purposes of our analysis and findings. We  interviewed officials from Army’s Health Care Acquisition Activity, the  Navy Medical Logistics Command, the Air Force Medical Service group,  the Joint National Capital Region Medical Command (JTF CapMed), and  TRICARE Management Activity (TMA). Additionally, we obtained and  analyzed information from these officials on the contracting arrangements  the departments used and any cost effectiveness studies that had been  completed. We also reviewed GAO reports on costs and outcomes  associated with different contracting approaches.
To determine the extent to which the military departments have  consolidated health care staffing requirements and to what effect, we  obtained data from each of the military departments as well as JTF  CapMed on the number and dollar value of department-identified  contracts with consolidated staffing requirements, including joint  contracts, contracts for medical services at joint military treatment  facilities (MTF), and multiple-award indefinite-delivery, indefinite-quantity  contracts. We relied on this data to present the percentage and total  dollar value of multiple-award indefinite-delivery, indefinite-quantity  contracts awarded by the military departments that were active in fiscal  year 2011. To assess the reliability of these data we interviewed officials  from the military departments on how they ensured the data were  accurate and reliable, and tested the data for any missing values or  obvious errors and then followed up with officials to obtain corrected data.
We found the data were sufficiently reliable for the purposes of our  analysis and findings. We spoke with officials from the military  departments’ contracting organizations to determine if cost savings could  be demonstrated based on the use of multiple-award contracts. We also  reviewed past reports by the Department of Defense (DOD), GAO, and  others.
To determine the percentage of contract health care professionals who  work at on-base MTFs versus off-base facilities, we requested that the  three military departments, JTF CapMed, and TMA provide us data on the  type, number of, and total obligations in fiscal year 2011 associated with  contract health care professionals providing direct patient care at all  MTFs and associated off-base clinics within the United States and her  territories in fiscal year 2011. For the purposes of our review, we  collected data on parent MTFs and those off-base facilities which were  under the purview of the MTF commander, were physically located  outside the military installation, received some direct care dollars, and  employed contract health care professionals. We defined a health care  professional as an individual providing primary, specialty, or ancillary  services at an MTF or associated off-base clinic who has received  specialized training or education in a health related field. We excluded  from our scope MTFs located outside of the United States; and we also  excluded contracts for research and development-related services, dental  and veterinary professions, as well as administrative, janitorial, food, or  housekeeping services. To assess the accuracy and completeness of the  reported data, we interviewed officials from the military departments on  how they ensured the data were accurate and reliable. We also tested the  data for any missing values or obvious errors and then followed up with  officials to get corrected data. Based on our analyses and discussions  with military department officials, we determined that caution should be  exercised when using their data to draw conclusions about the actual  number of contracted health care professionals in MTFs for any given  time period. However, because we are presenting the reported data at a  level where they describe a high level overview of the number of contract  health care professionals providing care at MTFs during our period of  review, we believe the data are sufficiently reliable for the purposes of our  review.
To determine the extent to which costs associated with contract health  care professionals at on-base and off-base facilities could be compared,  we met with contracting officials from the military departments, TMA, and  personnel at select MTFs to discuss the data we had received and the  proposed cost comparison. Based on the data received from the military  departments and these discussions, we concluded that DOD had not  conducted a similar cost comparison of on-base and off-base facilities,  and that the military department-reported data could not be used to  compare costs associated with on- and off-base facilities since the  number of off-base facilities was limited and costs associated with the  different facilities could not be appropriately compared for a number of  reasons, as indicated in this report. We were able to determine that the  data were sufficiently reliable to present information on the number of and  aggregate costs associated with contract health care professionals, but  not for the purposes of a comparison of costs associated with on-base  versus off-base facilities.
To determine the training requirements and experience of personnel  responsible for awarding and administering contracts for health care  professionals, we interviewed officials from the military departments’  contracting organizations and collected supporting documentation on  DOD-wide and military department-specific policy and requirements. For  the purposes of this review, we limited the scope of our analysis to  contracting officers and contracting officer’s representatives (COR). We  obtained additional descriptive information on the specific health care and  acquisition training and experience of contracting personnel at selected  medical facilities from each military department with small and large  numbers of contract health care professionals on staff. We selected  these facilities based on the number of full-time equivalent (FTE) contract  health care professionals the military departments reported to be working  at each MTF in fiscal year 2011. We also visited selected MTFs, including  three of the seven off-base clinics identified by the military departments,  and interviewed officials with knowledge of the training and experience of  contracting officers and CORs. Finally, we interviewed an official from the  Defense Acquisition University regarding training in personal services  contracts. We did not evaluate training records of contracting officers or  CORs for sufficiency.
To determine the extent to which the military departments have policies or  procedures that generally address legislated quality standards for  contract health care professionals and the staffing companies that provide  these professionals, we obtained documentation such as federal  regulations, DOD and military department-level policies and procedures,  and military department-wide standardized contracting language, as  provided to us by each of the military departments and JTF CapMed. We  reviewed this documentation to assess whether it generally addressed  the legislated quality standards in the National Defense Authorization Act  for Fiscal Year 2007, including the 2011 version of the Joint  Commission’s Health Care Staffing Services standards. We also  interviewed officials from DOD, each of the military departments, and JTF  CapMed to better understand how, if at all, the legislated quality  standards were incorporated into their policies and procedures for  contracting for health care professionals. Our analysis focused on  whether the policies and procedures generally addressed the legislated  standards; we did not assess the military departments’ compliance with  these standards.
To gain insight applicable to all objectives, we selected a  nongeneralizable sample of MTFs based on the military department, the  location, and the number of contract health care professionals at each  facility. We met with officials from Ft. Belvoir Community Hospital, Walter  Reed National Military Medical Center, Fairfax TRICARE Clinic, Dumfries  TRICARE Clinic, San Antonio Military Medical Center, Portsmouth Naval  Medical Center, and the TRICARE Prime Clinic Virginia Beach. We held  meetings or received written responses to questions from officials at Fox  Army Health Center, Saratoga Springs Naval Health Clinic, Wilford Hall  Ambulatory Surgical Center, and Andersen Air Force Base Clinic. While  the sample allowed us to learn about many important aspects of, and  variations in, contracting for health care professionals in military treatment  facilities, it was designed to provide anecdotal information, not findings  that would be representative of all MTFs worldwide. See appendix III for  complete list of MTFs.
We conducted this performance audit from July 2012 to May 2013 in  accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: Interactive Graphic Information for the Location of On-Base MTFs and the Number of FTEs at Each Location
section_title: Appendix III: Military Treatment Facilities and Total Contracted Full-Time Equivalents (FTE) by Military Department
subsections: section_title: Military department Army
section_title: Military department
section_title: Military department
section_title: Military department
paragraphs: Facility name  Grand Forks Air Force Base  Buckley Air Force Base (off-base primary military treatment facility)   Columbus Air Force Base  Brandon Clinic  (off-base facility associated with MacDill Air Force Base)  Walter Reed National Military Medical Center (Previously the Walter Reed Army  Medical Center and the National Naval Medical Center)
Dumfries TRICARE clinic (off-base clinic associated with Fort Belvoir  Community Hospital, previously Woodbridge Family Health Center)   Fort Belvoir Community Hospital (Previously Dewitt Army Community Hospital)
Fairfax TRICARE clinic (off-base clinic associated with Fort Belvoir Community  Hospital)
section_title: Appendix IV: The Joint Commission’s Health Care Staffing Services Standards, 2011
paragraphs: Appendix IV: The Joint Commission’s Health  Care Staffing Services Standards, 2011 1. The health care staffing services (HCSS) firm clearly defines its leadership roles.  2. The HCSS firm has a code of business ethics.  3. The HCSS firm addresses existing or potential conflicts of interest related to its internal and external relationships.  4. The HCSS firm complies with applicable laws and regulations.  5. The services contracted for by the HCSS firm are provided to customers.  6. The HCSS firm is accessible to customers and staff.  7. The HCSS firm addresses the resolution of complaints from customers and staff.  8. The HCSS firm identifies and takes steps to reduce safety risks.  9. The HCSS firm addresses emergency management.  1. The HCSS firm confirms that a person’s qualifications are consistent with his or her assignment(s).  2. As part of the hiring process, the HCSS firm determines that a person’s qualifications and competencies are consistent with his or  her job responsibilities.  3. The HCSS firm provides orientation to clinical staff regarding initial job training and information.  4. The HCSS firm assesses and reassesses the competence of clinical staff and clinical staff supervisors.  5. The HCSS firm encourages the improvement of clinical staff competence through ongoing educational activities.  6. The HCSS firm evaluates the performance of clinical staff.  1. Information management processes meet internal and external information needs.  2. The HCSS firm maintains health information and personnel records for clinical staff.  3. The HCSS firm preserves the confidentiality and security of information about clinical staff and customers.  4. The HCSS firm has a process for maintaining continuity of information.  1. The HCSS firm plans an organized, comprehensive approach to performance improvement.  2. The HCSS firm maintains the quality and integrity of its data.  3. The HCSS firm collects data to evaluate processes and outcomes.
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Debra A. Draper (Director);  Bonnie Anderson (Assistant Director); LaTonya Miller (Assistant Director);  Peter Anderson; Lori Atkinson; Jacob Leon Beier; E. Brandon Booth;  Richard Burkard; Virginia Chanley; Gayle Fischer; Linda Galib; Julia  Kennon; Victoria Klepacz; Heather B. Miller; Jeffrey Mayhew; Kenneth  Patton; Carol D. Petersen; and Roxanna Sun made key contributions to  this report.