Military Health System: Sustained Senior Leadership Needed to Fully Develop Plans for Achieving Cost Savings
Published: 2014-02-26T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: DOD’s MHS costs almost $50 billion annually and is expected to grow to $70 billion by 2028. The MHS governance structure has been the subject of many studies, some recommending major changes. In 2006, DOD considered potential governance structure changes but left its existing structure in place, approving instead a shared-services directorate to consolidate common MHS functions (e.g., shared information-technology services) that ultimately was never developed. In 2012, DOD announced the creation of the DHA by October 1, 2013, with seven main goals: (1) consolidate functions (shared services) common to DOD, (2) deliver more-integrated health care in areas with more than one military service, (3) establish more-standardized processes, (4) more-closely align financial incentives with health and readiness outcomes, (5) match other resources with missions, (6) deliver more primary care and other health services, and (7) better coordinate care over time and across treatment settings. Section 731 of the National Defense Authorization Act for Fiscal Year 2013 required DOD to provide three submissions in March, June, and September 2013, detailing its plan to reform the MHS.
This testimony addresses the additional actions that would increase transparency and enhance accountability of DOD’s reform plans. It is based primarily on (1) GAO’s November 2013 report which assessed DOD’s first two submissions of its reform plans to Congress and (2) selected updates. For the updates, GAO analyzed DOD’s third reform plan and interviewed a DOD representative.
section_title: What GAO Found
paragraphs: Department of Defense (DOD) senior leadership has demonstrated a commitment to oversee implementation of its military health system’s (MHS) reform and has taken a number of actions to enhance the reform efforts. For example, in March 2013, DOD chartered the MHS Governance Transition Organization to provide oversight, management, and support for the implementation. This entity is chartered to exist until October 2015, when the Defense Health Agency (DHA) is expected to reach full operating capability. Formation of this entity addresses an issue GAO reported on in April 2012—that DOD did not form such a team to oversee its 2006 MHS reform effort.
GAO’s November 2013 report identified several areas in DOD’s implementation plan where sustained senior leadership attention is needed to help ensure the reform achieves its goals including:
Undetermined staffing requirements : DOD did not have the data to determine how the creation of the DHA will affect the total number of MHS headquarters staff because it had not conducted an accurate baseline assessment of current staffing levels. Notwithstanding, using data that service officials later believed were inaccurate, in 2011, DOD identified anticipated annual personnel savings of $46.5 million as part of the rationale for creating the DHA.
Unclear cost estimates : DOD’s cost savings estimates were missing key details such as the source of the savings. DOD aggregated the separate functions of its shared services, which obscures the size and cost of planned efficiencies for each function. A business case analysis requires detailed information to convince customers and stakeholders that the selected business process is the appropriate means for achieving performance. In addition, business-case analyses should demonstrate the sensitivity of the outcome to changes in assumptions. However, DOD did not assess the risk that implementation costs could increase.
Incomplete performance measures : DOD did not develop explanations for how each measure relates to the goals of the reform effort, did not define the specific measure to be developed; did not provide a baseline assessment of the current performance that is to be measured; and, most importantly, did not identify quantifiable targets for assessing progress. In its third submission, DOD provided some additional information, but did not provide fully developed performance measures for any of its seven reform goals.
DOD concurred with all of GAO’s recommendations, including: (1) develop a baseline assessment of the number of personnel currently working within the MHS headquarters and an estimate for the DHA at full operating capability; (2) develop a more thorough explanation of the potential sources of cost savings from DOD’s implementation of shared services; and (3) develop performance measures that are clear, quantifiable, objective, and include a baseline assessment of current performance. In February 2014, a DOD representative said that DOD has taken action to address the recommendations, but it has not completed implementation. GAO continues to believe that it is imperative for DOD to complete these actions so decision makers will have complete information to gauge reform progress.

section_title: Letter
paragraphs: Thank you for the opportunity to be here today to discuss whether the  Defense Health Agency (DHA) is positioned to achieve the goals of the  Department of Defense’s (DOD) efforts to reform the military health  system (MHS). DOD plans to spend almost $50 billion on the MHS in  fiscal year 2014. This number has grown from approximately $20 billion in  fiscal year 2000, and is projected by the Congressional Budget Office to  continue to grow to $70 billion in 2028. In an effort to create a more  integrated and cost effective MHS, in March 2012, the Deputy Secretary  of Defense directed the establishment of a Defense Health Agency, which  officially began operations on October 1, 2013. Throughout the  implementation of the DHA, senior DOD leadership, including the Deputy  Secretary of Defense, the Assistant Secretary of Defense (Health Affairs),  and the service Surgeons General have demonstrated a commitment to  oversee implementation for reform of the MHS. However, we have  identified several areas where sustained senior leadership, including  additional information, is needed to help ensure the reform achieves its  goals, including greater cost effectiveness.
My statement today summarizes key findings from our November 2013  report which assessed DOD’s implementation plans for reform of the  MHS and includes selected updates. Specifically, it addresses: (1) the  staffing requirements of the DHA; (2) the sources of the cost savings that  DOD estimates will be realized from its shared-services goal, and the  importance of monitoring and more fully developing the associated  implementation costs; (3) milestones to assess progress in implementing  all seven goals of the reform efforts; and (4) performance measures to  evaluate achievement of the reform’s goals.
The National Defense Authorization Act for Fiscal Year 2013 required  DOD to submit its plans for implementing its reform effort in three  submissions—the first in March 2013, the second in June 2013, and the  third in September 2013—and mandated that we review DOD’s first two  submissions.
National Defense Authorization Act for Fiscal Year 2013, Pub. L. No. 112-239, § 731  (2013). well as an August 2013 supplemental report to Congress of DOD’s plan  to implement the reform effort and reported the results in November 2013.  For that report, we compared DOD’s submissions for reforming the MHS  governance structure with the statutory requirements and key  management practices contained in GAO’s Business Process  Reengineering Assessment Guide and other relevant GAO work. In the  course of our work, we interviewed officials from the Office of the  Assistant Secretary of Defense for Health Affairs, MHS Transition Office,  and the military Surgeons General. For the purposes of this testimony, in  February 2014, we subsequently examined DOD’s third and final reform  plan, which was submitted to Congress in November 2013, and  discussed the status of our November 2013 report recommendations with  an official within the Office of the Secretary of Defense (Health Affairs)  who represented the department. The work upon which this statement is  based was conducted 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. Additional details  about the scope and methodology can be found in our November 2013  report, and a list of related products appears at the end of my statement.
subsections: section_title: Background
paragraphs: Since 1949, the governance structure of the MHS has been the subject of  numerous studies conducted by DOD internal and external boards,  commissions, task forces, and GAO, and several of those studies have  led to recommendations for a major organizational realignment. After  studying several options for reorganizing the defense organizations that  constitute the MHS, in 2006 the Deputy Secretary of Defense approved  multiple initiatives including a shared services directorate to integrate the  services these organizations provide, such as information technology,  and make the MHS more cost-effective. DOD implemented those  initiatives to varying extents; however, the directorate was never formed  and the overarching governance structure of the MHS did not change.  Further, Congress expressed concern that DOD had not yet developed a  comprehensive plan to enhance quality, efficiencies, and savings in the  MHS.  DOD’s senior leadership established a task force in 2011 to review  various options for changing the governance structure of the system. This  task force reported the results of its review to the congressional defense  committees in March 2012 and, in October 2013, implemented its  recommended course of action by establishing the DHA. According to  DOD, with the creation of the DHA, the military services’ respective  Surgeons General will continue to oversee medical forces and the  operation of health care systems, including their military hospitals, and  the DHA will support the services in executing their respective medical  missions.
DOD created the DHA with the intent of creating a more cost-effective  and integrated MHS. This reform effort comprises seven overarching  goals: consolidate functions (shared services) common to DOD; deliver more-integrated health care in areas with more than one establish more-standardized processes; more-closely align financial incentives with health and readiness match other resources with missions; deliver more primary care and other health services; and better coordinate care over time and across treatment settings.
The Deputy Secretary of Defense directed the formation of a team to  develop an implementation plan for the governance changes. As a result,  in March 2013, the Assistant Secretary of Defense for Health Affairs  chartered the MHS Governance Transition Organization to provide  oversight, management, and support for the implementation of MHS  governance reforms. The formation of this MHS Governance Transition  Organization addresses an issue we previously reported on—that DOD  had not formed an overarching team to manage the implementation of the  2006 attempt to improve the department’s medical governance structure.
section_title: DOD Does Not Have an Accurate Baseline Assessment of Current Staffing to Determine Potential Savings and Future Staffing Needs of the DHA
paragraphs: As we reported in November 2013, DOD has not conducted an accurate  baseline assessment of the headquarters personnel currently working in  the MHS—that is, personnel working at each military service’s  headquarters and at the Office of the Secretary of Defense. In addition,  DOD has not determined the number of personnel required for the DHA  when it is fully operational in 2015, as currently planned. Our previous  work highlighted the need for federal agencies to have valid, reliable  data and to be aware of the size of their workforce, its deployment across  the organization, and the knowledge, skills, and abilities needed for the  agency to accomplish its mission. A baseline assessment of the number  of current headquarters personnel is a crucial first step for developing an  estimate of the number of personnel that will be required once DHA is  fully operational.
In its September 2011 analysis of options to reform the MHS, DOD  identified anticipated personnel savings as part of the rationale for the  reform effort and estimated a resulting estimated annual personnel cost  savings of $46.5 million. The Deputy Secretary of Defense based the  decision to establish the DHA, in part, on this estimate of personnel  savings. In contrast, we reported in November 2013 that DOD officials  told us that there would be no net increase in personnel numbers across  the MHS headquarters as a result of the creation of the DHA. Further, we  reported that, according to DOD officials, military service officials believed  that DOD’s previous baseline assessment that was reflected in the $46.5  million cost savings estimate did not accurately reflect the current number  of headquarters personnel working in the MHS.
We also reported in November 2013 that, according to DOD officials, the  number of military, civilian, and contractor positions required when the  DHA is fully operational in 2015 could be significantly higher for certain  headquarters functions than the estimates for the number of positions  required at the time of the DHA’s establishment in October 2013. For  example, we reported that according to a senior official responsible for  information technology in the MHS, the number of staff required to  provide information-technology services when DHA began initial  operations in October 2013 was estimated at about 400 military and  civilian positions; however, that estimate could increase to about 3,500  military and civilian positions and about 5,000 contractor equivalent  positions once the DHA becomes fully operational in 2015. We concluded  that DOD was unable to determine whether the establishment of the DHA  would result in an increase or decrease in the number of headquarters  personnel because the department had not completed an accurate  baseline assessment of the number of headquarters personnel working in  the MHS across the services and the Office of the Secretary of Defense.
In our November 2013 report, we recommended that DOD develop a  baseline assessment of the current number of military, civilian, and  contractor personnel currently working within the MHS headquarters and  an estimate for the DHA at full operating capability, including estimates of  changes in contractor full-time equivalents. DOD concurred with our  recommendation. In our November 2013 report, we noted that DOD  officials told us that they planned to conduct a baseline assessment of  headquarters staffing levels and submit a revised estimate of its staffing  needs in the department’s third and final implementation plan submission.  In the final submission which we reviewed for this statement, DOD did not  include a baseline assessment of the number of personnel currently  working in the MHS headquarters across the services and the Office of  the Secretary of Defense, nor did it include an estimate of the staffing  needs once the DHA is fully operational in 2015. Instead, DOD reported  that the DHA would include 1,941 military and civilian personnel as of its  initial operating capability on October 1, 2013. Additionally, the plan’s  estimate of staffing in October 2013 does not account for any contractor  positions currently associated with the MHS’s headquarters functions. As  the DHA moves toward full operating capability, accurate baseline staffing  data is critical for senior leadership to make informed decisions about the  resources required to manage the MHS. Such data have become even  more critical since the Deputy Secretary of Defense announced a           20 percent reduction in DOD management headquarters spending over    5 fiscal years beginning in fiscal year 2014.
section_title: DOD Has Not Clarified the Sources of Cost Savings and Its Plan to Monitor Implementation Costs
paragraphs: DOD has not provided discrete cost savings estimates for the various  functions it has identified as part of its 10 shared service projects it is  planning as part of the MHS reform. In addition, DOD has not clarified its  plan to monitor implementation costs. According to GAO’s Business  Process Reengineering Assessment Guide, an initial business case is a  high-level document aimed at convincing customers and stakeholders  that reengineering the selected business process is the appropriate  means for achieving performance and cost-savings goals. The Guide  identifies that as the reengineering process matures, the business case  should include detailed qualitative and quantitative analysis in support of  selecting and implementing the new process that includes a statement  regarding benefits, costs, and risks. In addition, business-case analyses  should demonstrate the sensitivity of the outcome to changes in  assumptions, with a focus on the dominant benefit and cost elements and  the areas of greatest uncertainty. In the context of major business- process reengineering efforts, such as DOD’s shared services,  implementation costs can be the dominant cost element and the area of  greatest uncertainty.
GAO-14-49.
DOD’s submissions did not include detailed quantitative analysis  regarding the sources of its cost-savings estimates or provide a basis for  or an explanation of key assumptions and rationales used in estimating  such savings. For example, DOD identified the consolidation of medical  logistics functions and a resulting aggregated cost-savings range of  between $132 million and $353 million from fiscal years 2014 through  2019. However, the plan did not explain which function within this area  (e.g., equipment or housekeeping) would be the larger source of those  savings. Similarly, DOD’s second implementation plan submission  identified that DOD plans to achieve savings in administration of its health  care plan for servicemembers, TRICARE, by closing walk-in help centers  and transitioning to a phone-based system. Further, it plans to achieve  savings through better coordination of TRICARE benefit payments with  other health insurers. However, as in the case of the consolidation of  medical logistics functions, DOD did not identify separate cost-savings  estimates for each planned effort (e.g., transitioning to a phone-based  system) and instead presented the estimated cost savings as an  aggregated amount of between $503 million and $787 million.
DOD’s second implementation plan submission included risk-adjusted  estimates of net cost savings for shared services based on uncertainty  regarding these projects’ effectiveness and that are presented as a range,  with a 10 percent to 100 percent chance of achieving the maximum  estimated savings for each shared service. However, while DOD  assessed the risk of its reforms failing to achieve their maximum potential  cost savings, it did not similarly assess the risk that estimated  implementation costs may increase and affect net savings. As noted  above, our prior work emphasizes that business-case analyses should  demonstrate the sensitivity of the outcome to changes in assumptions,  with a focus on the dominant benefit and cost elements and the areas of  greatest uncertainty. DOD’s analysis did not assess the risk that  estimated implementation costs may increase. In instances where  estimated implementation costs increase, overall savings may be  negatively affected.
DOD’s past experience with large-scale projects demonstrates its  difficulties in controlling rising implementation costs. For example, in  October 2010, we previously found that after obligating approximately     $2 billion over the 13-year life of its initiative to acquire an electronic  health record system, as of September 2010 DOD had delivered various  capabilities for outpatient care and dental care documentation, but scaled  back other capabilities it had originally planned to deliver, such as  replacement of legacy systems and inpatient-care management. In  addition, users continued to experience significant problems with the  performance (speed, usability, and availability) of the portions of the  system that have been deployed. According to DOD’s estimates,  collectively, the 10 shared services to be implemented as part of the MHS  reform effort require an investment in information-technology capabilities  of about $273 million between fiscal years 2014 and 2019. Given DOD’s  past experience in this area, rising implementation costs are an area of  specific concern.
In our November 2013 report, we recommended that DOD develop a  more thorough explanation of the potential sources of cost savings from  the implementation of its shared-services projects and monitor the cost of  the implementation process, and DOD concurred with our  recommendations.submission did not provide additional information concerning the potential  sources of cost savings, nor did it clarify its plan to monitor  implementation costs. In February 2014, a DOD representative told us  that DOD has developed a process for leadership to monitor  implementation costs, and we plan to review DOD’s process to determine  if it addresses our recommendation. As DOD implements its shared  services, greater clarity with regard to the sources of cost savings is also  needed to allow senior leaders to monitor progress in achieving cost  savings.
section_title: DOD Does Not Have Interim Milestones For All Reform Goals
paragraphs: DOD has developed some milestones and activities associated with each  of its reform goals, including identifying steps to reach each reform goal’s  initial operating capability. However, DOD did not consistently identify  milestones between initial operating capability and final operating  capability, nor did it include steps to achieve all seven reform goals.  Practices of successful performance management show that interim  milestones can be used to show progress towards implementing efforts or  to make adjustments when necessary. Specifically, we found that  developing and using specific milestones and timelines to guide and  gauge progress toward achieving an agency’s desired results informs  management of the rate of progress toward achieving goals and whether  adjustments need to be made in order to maintain progress within given  time frames.
DOD’s March 2013 submission was required to include a detailed  schedule for carrying out the reform of the governance of the MHS,  including a schedule for meeting the goals of the reform. However, in that  submission, DOD provided a schedule of activities leading up to its first  major milestone—initial operating capability of October 1, 2013. This  schedule of activities did not provide information related to activities  beyond this first major milestone, and it did not present milestones for  achieving each of the supporting seven goals of the reform. In that March  2013 submission, DOD also did not include some key features of effective  schedules identified in our prior work, such as interim milestones or  related timelines for all of the activities supporting the reform. Specifically,  the submission did not contain any interim actions or milestones between  October 1, 2013 and October 1, 2015—the planned final operating  capability date. Furthermore, the schedule provided in the submission  does not clearly establish how each of the supporting seven goals of the  reform will be met.
Subsequent to DOD’s March 2013 submission, the House Report  accompanying a bill for the National Defense Authorization Act for Fiscal  Year 2014 directed the Secretary of Defense to provide the House Armed  Services Committee with, among other things, a detailed schedule for  managing the reform effort. In response, DOD submitted a supplemental  report on August 16, 2013, that included estimated interim milestones for  the achievement of three of the reform goals that it had not initially  provided in either of its earlier submissions.
In our November 2013 report, we recommended that DOD develop a  comprehensive timeline that includes interim milestones for all reform  goals that could be used to show implementation progress, and DOD  concurred with our recommendation. DOD’s third implementation plan  submission contained additional timeline activities for its reform goal  concerning the implementation of shared services, with milestones  leading up to each shared services’ initial operating capability. However,  DOD has not consistently identified milestones for all activities between  initial operating capability and final operating capability for each of the  goals of its reform. While senior leaders now have more interim  milestones by which to track the implementation of the DHA, they  continue to lack milestones subsequent to initial operating capability in a  number of areas. Unless DOD develops interim milestones for its reform  timelines, it may not be able to adequately monitor its progress toward  achieving its goals by October 2015.
section_title: DOD Does Not Have Fully Developed Performance Measures That Could Be Used to Assess Progress in Establishing the DHA
paragraphs: DOD did not include critical details in the performance measures it  developed to assess progress in achieving the seven goals of the reform  effort. Specifically, DOD did not develop explanations for how each  measure relates to the goals of the reform effort; did not define the  specific measure to be developed; did not provide a baseline assessment  of the current performance that is to be measured; and, most importantly,  did not identify quantifiable targets for assessing the progress of each  reform goal.
We have previously concluded that federal agencies engaging in large  projects, including the consolidation of management functions, can use  performance measures to determine how well they are achieving their   Additionally, we  goals and identify areas for improvement, if needed.have found that by tracking and developing a performance baseline for all  measures, agencies can better evaluate progress made and determine  whether goals are being achieved. Identifying and reporting deviations  from the baseline as a program proceeds provides valuable information  for these decision makers as they identify areas of risk and diagnose their  causes.
GAO-14-49. As noted in our report, some performance measures were used to assess  multiple objectives. performance measures that we had established in our prior work.Specifically, we found that DOD provided only the measures’ names, with  no accompanying explanation for how each measure relates to the goals  of the reform effort, definition of the specific measure to be developed, or  quantifiable, numerical target for performance, nor had DOD provided a  baseline assessment of the current performance to be measured. For  example, DOD listed “Emergency Room Utilization Rate” as a  performance measure, but did not explain how that measure relates to  the objective of consolidating delivery of health care in areas with more  than one military service. Further, we found that DOD did not provide an  explanation of what each measure will evaluate, which could be used to  determine the extent to which each measure provides new information  beyond that provided by other measures. For example, two of the  measures listed under the objective to deliver more-comprehensive  primary care and integrated health services using advanced patient- centered medical homes are “satisfaction with provider communications”  and “satisfaction with health care.” As presented in DOD’s June  submission of its implementation plan, it is unclear whether there is any  overlap between these measures, because the aspects of satisfaction are  not clarified by any accompanying explanation or definition.
We also reported that decision makers would not be able to determine the  objectivity of DOD’s measures because there is no information  accompanying the measures that indicates specifically what is to be  observed, in which population or conditions, and in what time frame. For  example, one of the measures is “savings achieved versus savings  projected.” This measure does not indicate specifically how savings will  be measured, and does not indicate what time frame will be used to  compare what savings were projected versus what were actually  achieved.
In our November 2013 report, we recommended that DOD provide more  detailed information on its performance measures—specifically, that DOD  develop and present to Congress measures that are clear, quantifiable,  objective, and include a baseline assessment of current performance.the third submission of its implementation plan, DOD provided some  additional information, such as baselines and performance targets, for the  performance measures under two of its seven reform goals. In this  submission, DOD included tables with expanded information for the  performance measures for its goals related to (1) delivering more- comprehensive primary care and integrated health services using  advanced patient-centered medical homes, and (2) coordinating care  over time and across treatment settings to improve outcomes in the  management of chronic illness, particularly for patients with complex  medical and social problems. For these objectives, DOD listed the  measures’ names, and, where available, estimates of current and target  performance. For those measures without a definition or baseline, DOD  provided a date by when the measures would be defined and when the  baseline performance level would be established.
As of DOD’s final submission, much of the information to be included in  these two tables was still to be determined. As a result, many of the  entries in the tables represented placeholders for information, rather than  actual baselines or performance targets. Further, DOD did not include this  additional information for any of the performance measures listed under  its other five reform goals. In this third submission, DOD noted that it was  in the process of developing measures and respective performance  targets to be published in its 2014 strategic plan for the MHS, which it  expected to issue in December 2013. In February 2014, a DOD  representative told us that the strategic plan is now expected to be  released in May 2014. Fully developed performance measures are key to  senior leaders’ ability to assess if DOD’s reform effort is achieving its  goals or if corrective action is required.
In summary, DOD’s reform efforts represent positive steps to improve the  efficiency of the governance of the MHS, and these reforms have  progressed much further than previous attempts to improve the  governance structure. As we noted in previous reports, the successful  implementation of the DHA will require committed senior leadership to  sustain the momentum created by the current reform effort. This  leadership, in turn, will help to provide oversight and accountability for the  improvement process. However, senior leaders need appropriate  information to make decisions and guide the reform. The first step to  determine what is needed for the implementation of the DHA is a baseline  assessment of current MHS staffing, followed by an estimate of DHA  staffing at full operating capability. In addition, a detailed quantitative  analysis regarding the sources of cost savings and a plan to monitor  implementation costs would provide greater clarity to DOD’s shared- service consolidation projects. Moreover, the development of  comprehensive milestones for all of the reform goals would allow decision  makers to track the progress of DOD’s reform efforts toward achieving its  goals. Finally, the completion of a set of fully developed performance  measures across all seven of DOD’s stated goals for the DHA would  ensure that DOD’s senior leaders and other decision makers have the  necessary information to assess DOD’s progress in creating a more cost- effective and integrated MHS.
Chairman Wilson, Ranking Member Davis, and Members of the  Subcommittee, this concludes my prepared statement. I would be  pleased to respond to any questions that you may have at this time.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: For further information about this statement, please contact             Brenda S. Farrell at (202) 512-3604 or farrellb@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be  found on the last page of this statement. Individuals who made key  contributions to this testimony are Lori Atkinson, Assistant Director;  Beckie Beale; Jeff Heit; Mae Jones; and Adam Smith.
section_title: Related GAO Products
paragraphs: Defense Health Care Reform: Additional Implementation Details Would  Increase Transparency of DOD’s Plans and Enhance Accountability.  GAO-14-49. Washington, D.C.: November 6, 2013.
Defense Health Care: Additional Analysis of Costs and Benefits of  Potential Governance Structures Is Needed. GAO-12-911. Washington,  D.C.: September 26, 2012.
Defense Health Care: Applying Key Management Practices Should Help  Achieve Efficiencies within the Military Health System. GAO-12-224.  Washington, D.C.: April 12, 2012.
Opportunities to Reduce Potential Duplication in Government Programs,  Save Tax Dollars, and Enhance Revenue.   GAO-11-318SP. Washington, D.C.: March 1, 2011.
Military Personnel: DOD Addressing Challenges in Iraq and Afghanistan  but Opportunities Exist to Enhance the Planning Process for Army  Medical Personnel Requirements. GAO-11-163. Washington, D.C.:  February 10, 2011.
Military Personnel: Enhanced Collaboration and Process Improvements  Needed for Determining Military Treatment Facility Medical Personnel  Requirements. GAO-10-696. Washington, D.C.: July 29, 2010.
Defense Health Care: DOD Needs to Address the Expected Benefits,  Costs, and Risks for Its Newly Approved Medical Command Structure.  GAO-08-122. Washington, D.C.: October 12, 2007.
Defense Health Care: Tri-Service Strategy Needed to Justify Medical  Resources for Readiness and Peacetime Care. GAO/HEHS-00-10.  Washington, D.C.: November 3, 1999.
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