Military Personnel: DOD Needs to Improve Dental Clinic Staffing Models and Evaluate Recruitment and Retention Programs
Released: 2018-12-13T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: DOD has taken steps to modernize its Military Health System to ensure that it operates efficiently. For example, in September 2013, the Defense Health Agency was created, in part, to implement common clinical and business processes across the services. Essential to this effort are the services' ability to effectively staff their medical facilities, including the processes used for staffing dental clinics and the services' ability to recruit and retain military dentists.

Senate Report 115-125 included a provision for GAO to review the services' processes for determining requirements for dentists and its programs for recruiting and retaining military dentists, among other things. GAO assessed the extent to which the services (1) use validated dental clinic staffing models that also incorporate cross-service staffing standards, and (2) have recruited and retained military dentists and measured the effectiveness of their recruitment and retention programs. GAO assessed service dental clinic models, analyzed recruitment and retention data from fiscal year 2012 through 2016, and interviewed DOD and service officials.

section_title: What GAO Found
paragraphs: The Army and the Air Force use validated staffing models for their respective dental clinics, and the Navy has developed a model that is under review. The Army and the Air Force's models are based on service-specific staffing standards. For example, the Army's model generally projects dental clinic staffing based on historical facility data and, according to officials, the Air Force model is largely a population-based model that requires one dentist for every 650 servicemembers. In contrast, in the absence of a validated model, officials stated that, the Navy uses a general ratio of one dentist for every 1,000 servicemembers to staff its dental clinics. The Navy has developed a model that is under review, and if approved, according to officials, will be subject to the Navy's validation processes.

While the services have developed and implemented cross-service staffing standards for 42 medical specialties, according to a key official involved in developing these standards, they currently do not plan to develop a similar set of standards for dental care. Cross-service staffing standards help the services standardize clinic staffing to address the common day-to-day health needs of patients. Service officials maintain that they must operate their respective dental clinics autonomously and in a manner that best supports their service-specific needs and unique command structures. However, as oral health requirements for servicemembers are standardized across the Department of Defense (DOD), it is unclear why dental care has been excluded from the staffing standardization effort—especially because the services have implemented cross-service staffing standards for 42 other medical specialties.

The Army, the Navy, and the Air Force meet their needs for military dentists by recruiting both dental students and fully qualified dentists. The services generally met their recruitment goals for dental students between fiscal years 2012 and 2016, but faced challenges recruiting and retaining fully qualified dentists during that period. For example, the Army missed its recruitment goals for fully qualified dentists in all 5 years, the Navy missed its goals in 2 out of 5 years, and the Air Force missed its goals in 3 out of 5 years. These challenges are most pronounced for certain specialties. For example, service data indicate that the Army and the Navy were unable to recruit any oral surgeons, while the Air Force recruited 50 percent of the oral surgeons it needed. Service officials cited various reasons for not meeting recruitment goals, including the availability of more lucrative careers in the private sector and quality of life concerns associated with military service.

The services rely on various programs, including scholarships and special pay and incentives, to attract and retain military dentists, and service officials stated that they monitor their programs by reviewing their goals, among other actions. However, GAO found that some services continue to provide incentive bonuses for positions that are overstaffed and have met or exceeded recruitment goals, but they do not know whether this is necessary because they have not evaluated the effectiveness of their programs. Without evaluating their programs, the services lack the information necessary to ensure that they are using recruitment and retention incentives effectively and efficiently for attracting and retaining dentists.

section_title: What GAO Recommends
paragraphs: GAO recommends that each of the services develop cross-service staffing standards to be incorporated into their staffing models, and evaluate the effectiveness of their recruitment and retention programs. DOD did not provide comments on a draft of this report.

section_title: Letter
paragraphs: In recent years, the Department of Defense (DOD) has taken steps to  modernize its Military Health System to ensure that it operates as  efficiently as possible in the delivery of health services, while fully  supporting its mission and maintaining medical readiness. Key to this  modernization is ensuring that the Military Health System has the right  number of medical providers, including dentists, with the requisite skill set  and competencies to staff its Military Treatment Facilities (MTF). Military  dentists practice across all major dental specialties with the primary  mission of ensuring the dental readiness of all active duty  servicemembers.

According to a February 2015 U.S. Department of Health and Human  Services report, projected future nationwide shortages of dentists are  anticipated through 2025 as the demand for dental care in the United  States exceeds supply. Projected nationwide shortages of dentists  emphasize the importance for DOD to ensure its dental clinics are  adequately staffed and the services are able to recruit and retain certain  dental specialists. In 2010, we found that DOD’s processes for  determining MTF personnel requirements could be improved, and we  made recommendations aimed at enhanced collaboration across the  services. Specifically, we recommended that by identifying shared  medical capabilities, the services would benefit from the development of  cross-service standards for determining the amount of personnel needed  to meet the day-to-day health needs of the patient population. We also  made recommendations aimed at ensuring the validity and verifiability of  their MTF staffing models. DOD generally concurred with these  recommendations and took actions to implement them. These  recommendations and DOD’s actions are discussed in more detail in  subsequent sections of this report.

Senate Report 115-125, accompanying a bill for the National Defense  Authorization Act for Fiscal Year 2018, included a provision for us to  review the services’ processes for determining requirements for dentists  and DOD’s programs for recruiting and retaining military dentists, among  other things. This report assesses the extent to which the services (1)  use validated dental clinic staffing models that also incorporate cross- service staffing standards, (2) have recruited and retained military  dentists, and are measuring the effectiveness of their recruitment and  retention programs.

To address our first objective, we reviewed DOD, Army, Navy, and Air  Force policy and guidance for reviewing and validating workforce  models. We described the processes the services use for reviewing and  validating their dental clinic staffing models as it pertains to this guidance.  We interviewed officials with the Army Medical Command, the Navy  Bureau of Medicine and Surgery, and the Air Force Medical Service, as  well as officials from each service’s dental corps and other service  organizations who are responsible for the development, operation, and  implementation of these models. We reviewed the models and  interviewed service officials to determine similarities and differences  within the methodologies used in the models and processes, and  assessed the extent to which the services collaborated in the  development of their models and based their models on common  standards.

To address our second objective, we analyzed the extent to which the  services have met their recruitment goals for military dentists during fiscal  years 2012 through 2016, the most recent year for which data were  available at the time of our review. We assessed the reliability of these  data by obtaining and reviewing information from the services regarding  the processes and internal controls that are in place to ensure the  reliability and quality of the data. Based on our review, we believe these  data are sufficiently reliable for the purposes of this report. Additionally,  we used data from DOD’s Health Manpower and Personnel Data System  (HMPDS) and service-level data for fiscal years 2012 through 2016 to  assess the extent to which the Army, the Navy, and the Air Force (1) have  met authorized end-strengths for dentists, (2) are retaining dentists, and  (3) have gaps in dental specialties. We selected this timeframe to enable  us to evaluate trends over time, and fiscal year 2016 was the most recent  year of HMPDS and service-level data available at the time of our review.  We assessed the reliability of the HMPDS and service-level data by  collecting information and interviewing officials to determine how the  services and the Defense Manpower Data Center compile the data and  what internal controls are in place to ensure their reliability. We found  these data to be sufficiently reliable for the purposes of this report.

Additionally, we reviewed DOD’s special and incentive pay plan and other  DOD policies and guidance related to DOD recruitment and retention  programs. We interviewed officials and received written responses from  the services regarding their identified gaps, the programs they use to  address gaps in dental specialties, and any challenges they experience in  recruiting and retaining dentists. We also interviewed officials with the  Office of the Assistant Secretary of Defense for Health Affairs as well as  each service’s dental corps regarding the programs used and the  measures in place to evaluate the effectiveness of any such programs.  We reviewed our prior work on effective strategic workforce planning,  which state agencies should periodically measure their progress toward  meeting human capital goals and the extent that human capital activities  contributed to achieving programmatic goals and provide information for  effective oversight by identifying performance shortfalls and appropriate  corrective actions. Further, we reviewed Standards for Internal Control  in the Federal Government, including requirements for monitoring internal  control systems and evaluating results.

We conducted this performance audit from August 2017 to December  2018 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
paragraphs: The Military Health System is responsible for, among other things,  assuring the overall oral health of all uniformed DOD personnel. As part  of this health system, each service’s dental corps provides dental care for  its servicemembers. The Army, the Navy, and the Air Force Dental Corps  include approximately 3,000 active duty dentists and approximately 247  (200 in the United States) dental clinics to serve over 1.3 million  servicemembers.

Unlike their medical counterparts, the services’ dental corps rarely  provide beneficiary care, according to service officials. The primary role  of military dentists is to ensure the oral health and readiness of  servicemembers. Servicemembers’ oral health is evaluated using  standardized measures to determine the extent to which they are  deployable. Generally, servicemembers with identified urgent, emergent,  or unknown dental treatment needs are not considered to be worldwide  deployable until their oral health is adequately addressed.
subsections: section_title: Becoming a Military Dentist
paragraphs: Most military dentists enter service through the Armed Forces’ Health  Professions Scholarship Program (AFHPSP), a scholarship program  available to students enrolled in or accepted to dental school. Under the  services’ AFHPSP program, DOD pays for tuition, books, and fees, and  provides a monthly stipend. In return, the students incur an obligation to  serve 6 months of active duty service for each 6 months of benefits  received, with a 2-year minimum obligation. AFHPSP dental students  can pursue either a Doctor of Dental Surgery or Doctor of Dental  Medicine degree to become a general dentist.

In addition to the AFHPSP program, the services recruit fully qualified  licensed dentists. For example, individuals may become military dentists  through direct accessions, either by entering the service as a fully trained,  licensed dentist or through the Financial Assistance Program, which  provides stipends for dentists accepted or enrolled in a residency  program. For additional information on these and other recruitment  programs, see appendix I.

Regardless of the recruitment program, dentists may begin to practice  after obtaining a degree and completing licensure requirements. Military  dentists may pursue postgraduate training through a general dentistry  program, such as the Advanced Education in General Dentistry Program,  a general practice residency, or a specialty dental program offered  through the Uniformed Services University of the Health Sciences  Postgraduate Dental College. Postgraduate dental college includes  training and/or residency within a specific specialty and typically requires  between 1 to 6 years of additional training. While in a postgraduate dental  college program, participants incur an additional 6 months of active duty  service obligation for each 6 months in training, with a minimum of 2  years active duty service obligation. However, this obligation can be  served concurrently with obligations already incurred through AFHPSP if  incurred through sponsored postgraduate education in a military or  affiliated program. Figure 1 portrays the path to becoming a military  dentist and the active duty obligation incurred for AFHPSP dental  students.

Each service takes steps to validate whether the military dentist has the  appropriate professional qualifications and clinical abilities. Validation  includes ensuring the dentist is credentialed and privileged to practice.

See appendix II for more details on service processes for monitoring  qualification and performance of dentists.

section_title: Roles and Responsibilities for the Recruitment and Retention of Military Dentists
paragraphs: The Assistant Secretary of Defense for Health Affairs (ASD(HA)) serves  as the principal advisor for all DOD health policies and programs. The  ASD(HA) issues DOD instructions, publications, and memorandums that  implement policy approved by the Secretary of Defense or the Under  Secretary of Defense for Personnel and Readiness and governs the  management of DOD medical programs. The ASD(HA) also exercises  authority, direction, and control over the President of the Uniformed  Services University of the Health Sciences (USUHS). Further, ASD(HA)  sets the special and incentive pay amounts for all military dentists. The  ASD(HA) reports to the Under Secretary of Defense for Personnel and  Readiness, who in turn reports to the Secretary of Defense.

The Army, the Navy, and the Air Force medical commands and agencies  report through their service chiefs to their respective military department  secretaries and then to the Secretary of Defense. The Army, the Navy,  and the Air Force have the authority to recruit, train, and retain dentists.  Each military service has its own organizational structure and  responsibilities. See figure 2.

In September 2013, the Defense Health Agency was established to  support greater integration of clinical and business processes across the  Military Health System. The Defense Health Agency, among other things,  manages the execution of policies issued by the ASD(HA) and manages  and executes the Defense Health Program appropriation, which funds the  services medical departments. By no later than September 30, 2021, the  Director of the Defense Health Agency will assume responsibility for the  administration of each military treatment facility, to include budgetary  matters, information technology, and health care administration and  management, among other things. Although military treatment facilities include dental clinics, DOD initially intended to exclude dental care  (except oral and maxillofacial surgery), from the transfer to the Defense  Health Agency. However, as of September 2018, DOD stated it is  assessing the extent to which dental care will fall under the Defense  Health Agency’s administration.

section_title: GAO’s Prior Work on Military Treatment Facility Staffing Models and Tools
paragraphs: In July 2010, we found that the services’ collaborative planning efforts to  determine staffing of medical personnel working in fixed military treatment  facilities, including dentists, were limited, and that their staffing models  and tools had not been validated and verified in all cases as DOD policy  requires. Specifically, we found that some Army specialty modules  contained outdated assumptions, and that only a portion of the models  had been completely validated. We also found that the Navy did not have  a model, but instead employed a staffing tool that used current manning  as a baseline and adjusted its requirements based on emerging needs or  major changes to its mission. However, the Navy’s tool was not validated  or verified in accordance with DOD policy. Further, we found that the Air  Force may not know its true medical requirements because the model it  relied on also was not validated or verified.

We made several recommendations in our 2010 report, two of which were  aimed at improving staffing of MTFs. Specifically, we recommended that  the services identify common medical capabilities shared across military  treatment facilities and develop and implement cross-service medical  staffing standards for these capabilities as appropriate. We also  recommended that each service update or develop medical personnel  requirements determination tools as needed to ensure that they use  validated and verifiable processes.

The Army, the Navy, and the Air Force have implemented our  recommendation related to the development and implementation of validated and verifiable tools for developing medical personnel  requirements. Additionally, they identified and developed standardized  cross-service staffing standards for over 40 medical specialties and  incorporated them into their individual MTF staffing tools.

section_title: Two of Three Services Use Validated Dental Clinic Staffing Models, and None of the Models Incorporate Cross- Service Standards
subsections: section_title: The Army and the Air Force Use Validated Dental Clinic Staffing Models, and the Navy’s Proposed Model Is under Review
paragraphs: The Army and the Air Force have validated the dental clinic staffing  models that they use, and the Navy’s draft model is under review. In the  absence of a validated model, the Navy uses a general ratio to staff its  dental clinics. See table 1 for a description of each of the services’  methodology for staffing dental clinics.

The Army and the Air Force models, which were developed in  accordance with DOD guidance and service-specific requirements,  are subject to the following validation processes:

Army. Since 2011, the Army has used the Army Dental Clinic Model,  which, according to officials, is intended to determine the minimum  number of dentists necessary, by location, to ensure the medical  readiness of soldiers. Army staffing models are subject to validation  by the U.S. Army Manpower Analysis Agency, which validated the  Army’s Dental Clinic Model when it was developed in 2011.  According to an Army official, the model’s validation expired in 2014,  and was not re-validated until May 2018 due to limited resources.  Additionally, Army officials stated that the data used in the model are  updated on an annual basis and that the model is subject to  revalidation every 5 years.

Air Force. Since 2014, according to Air Force officials, the Air Force  has used its Dental Manpower Model to determine the minimum  number of dentists required, by clinic, to ensure the medical readiness  of servicemembers served by Air Force dental clinics. According to Air  Force officials, the Air Force Dental Manpower Model is subject to  review and validation that includes input from the Air Force Medical  Service; Surgeon General’s Manpower, Personnel, and Resources  office; Air Force Personnel Center; and consultants. Officials told us  the model is reviewed and validated annually and presented to the  Dental Operations Panel and Air Force’s medical service corporate  structure. The model was most recently validated in April 2018.

According to Navy Bureau of Medicine and Surgery (BUMED) officials,  the Navy does not yet have a model and therefore instead uses a general  ratio of one dentist for every 1,000 sailors as a baseline to initially  determine the staffing requirements of its dental clinics. This ratio is  adjusted based upon emerging needs or major changes to mission. In  2013, according to Navy officials, BUMED began developing a Dental  Services Model that could be used to determine dental clinic staffing  needs. In November 2016, BUMED internally released a draft report recommending that the dental corps approve and implement the Dental  Services Model as the staffing standard for dental clinics. According to a  Navy official, this report was provided to dental corps leadership for  review in July 2018 and they are expected to complete their review in  October 2018. According to BUMED officials, if the dental corps  leadership approves the model for use as an official staffing standard, the  model would be subject to official Navy validation processes which, in  accordance with DOD policy, would entail verification and validation  throughout the model’s lifecycle. Conversely, if the dental corps decides  to use the model as an informal staffing tool to supplement its current  processes, a BUMED official stated that it will be subject to an ad-hoc  internal review every 3 years that mirrors the Navy’s review of its  validation process.

section_title: The Services Have Not Developed Cross-Service Staffing Standards for Dental Care
paragraphs: Currently, the Army, the Navy and the Air Force each use different  service-specific standards and other factors to determine the number of  dentists needed at their respective dental clinics. As previously  discussed, the services have developed and are in the process of  implementing cross-service staffing standards—that is, a standardized  approach to staffing the common day-to-day health needs of the patient  population—for certain medical specialties. In response to DOD policy  and our 2010 recommendation, the services established a working group  to identify and develop common cross-service staffing standards, and in  2017, the tri-service working group established such standards for 42  different medical specialties. These standards are based on actual  workload data for common capabilities within selected medical specialties  and were incorporated into each service’s staffing tools to provide  consistent values for the minimum number of staff required to meet  patient needs. However, according to an official involved in the  development of the standards, the services have not collaborated to  develop a plan to establish a similar set of standards for dental care.

DOD guidance directs modeling and simulation management to develop  plans and procedures and to pursue common and cross-cutting modeling  tools and data across the services. Also, the ASD(HA) has supported  the effort to establish consistent workload drivers across services for  determining personnel requirements for MTFs.

According to a tri-service working group co-chair, they did not develop  cross-service staffing standards for dental care because at the time, the  quality of available data on dental procedure frequency and duration  varied across the services. The same official stated that these data have  been improved, but they still do not have plans to develop cross-service  staffing standards for dental care. Additionally, service officials  maintained that they must operate their respective dental clinics  autonomously and in a manner that best supports their service-specific  needs and unique command structures. Specifically, officials from each  service’s dental corps stated that their primary mission is focused on the  medical readiness of servicemembers and generally does not involve  beneficiary care. As such, they have not collaborated on staffing efforts  with the other services.

While we recognize that each service operates under a different  command structure, readiness requirements for oral health are  standardized across DOD, and all servicemembers are required to meet  the same level of oral health in order to be deployable. Additionally, since  DOD is currently assessing whether it will consolidate the services’ dental  corps staff under the Defense Health Agency’s administration, it  remains unclear to us why dental care has been excluded from cross- service efforts to develop a common set of standards for staffing military  dental clinics—especially because the services have developed common  staffing standards for42 other medical specialties.

section_title: The Services Generally Have Met Goals for Recruiting Dental Students, but Not for Fully Qualified Dentists and Do Not Know the Extent to Which Certain Programs Are Effective at Helping Recruit and Retain Dentists
paragraphs: The Army, the Navy, and the Air Force have generally met their  recruitment goals for dental students, but generally have not met their  recruitment goals for fully qualified dentists to address oral health needs  of the services. Overall, we found that the services maintained their  staffing levels for military dentists during fiscal years 2012 through 2016,  but experienced gaps within certain specialties. Further, the services  rely on various programs and special pays and incentives, to recruit and  retain military dentists, but they do not know the extent to which some of  these programs are effective at helping them to do so.
subsections: section_title: The Services Generally Met Recruitment Goals for Dental Students, but Faced Challenges Recruiting Fully Qualified Dentists
paragraphs: Our analysis of Army, Navy, and Air Force data found that in fiscal years  2012 through 2016, the services generally met their goals for dental  students recruited through the Armed Forces Health Professions  Scholarship Program (AFHPSP). From fiscal year 2012 through fiscal  year 2016, the Army met 94 percent of its goals, the Navy met 100  percent of its goals, and the Air Force met 97 percent of its goals. Figure  3 shows the AFHPSP recruitment goals and achievements, by service for  fiscal years 2012 through 2016.

To address their immediate need for dental providers, the services also  recruit fully qualified general dentists or specialists. However, the services  have experienced challenges meeting their recruitment goals for fully  qualified dentists. Figure 4 below shows the recruitment goals and  achievements for fully qualified dentists from fiscal years 2012 through  2016. As shown in the figure, the Army did not meet its recruitment goals  for 5 consecutive years, the Navy did not meet its goals for 2 of these 5  years, and the Air Force did not meets its goals for 3 of these 5 years.

While the services have experienced challenges in recruiting fully  qualified dentists, the challenges are most pronounced in certain  specialties. For example, based on our analysis of service data from fiscal  years 2012 through 2016, the Army and the Navy were unable to recruit  any oral surgeons and the Air Force recruited 50 percent of the oral  surgeons it needed. Service officials cited various reasons for not being  able to meet their recruitment goals for certain specialties, including the  availability of more lucrative careers in the private sector and quality of life  concerns associated with military service, such as frequent moves.  Additionally, Air Force officials stated that they are not always able to  offer accession bonuses consistently, which has caused challenges in  recruiting. Table 2 shows the recruitment goals and percentage  achieved for fully qualified dentists, by specialty, from fiscal years 2012  through 2016.

section_title: The Services Have Maintained Overall Staffing Levels for Military Dentists, but Have Experienced Challenges Retaining Certain Specialties
paragraphs: While the services maintained overall staffing levels for military dentists,  they have experienced some challenges retaining certain specialties.  Overall, military dentist end strengths—the actual number of dentists on  board at the end of the fiscal year—have generally met or exceeded  dental authorizations. Specifically, between fiscal years 2012 and 2016,  the Army’s dental authorizations were filled, on average, at about 109  percent, the Navy’s at about 101 percent, and the Air Force’s at about 97  percent. Further, DOD data show that average overall gain rates are  equal to average overall loss rates for the services’ dental corps in fiscal  years 2012 through 2015 at approximately 10 percent for the Army, 9  percent for the Navy, and 11 percent for the Air Force. Additionally,  according to our analysis of Army and Navy data, on average,  approximately 73 percent of Army dentists continue on active duty after 5  years of service, and approximately 63 percent of Navy dentists continue  on active duty after 5 years of service. According to Air Force officials, the  Air Force does not routinely track data on the number of dentists that  continue on active duty after 5 years of service.

Although the services have been able to maintain their overall numbers  for the total number of dentists in their respective dental corps, we found,  based on the data the services provided us, that each service  experienced gaps in certain dental specialties, including critically short  wartime specialties. For example, all of the services experienced gaps  in comprehensive dentistry from fiscal years 2012 through fiscal year  2016. In addition, for the same time period, all of the services  experienced gaps in prosthodontists and oral surgeons. Officials from all  three services cited family concerns, frequent moves, and competition  from the private sector as reasons why these and other dentists choose  to leave the military. Additionally, Army and Navy officials cited limited  training and education opportunities and limited scope of practice as  reasons why specialists such as oral surgeons leave the military.

section_title: The Services Monitor Their Recruitment and Retention Programs, but Do Not Know Whether The Programs Are Effective
paragraphs: The services rely on programs, such as AFHPSP, the Critical Wartime  Skills Accession Bonus (CWSAB), and special pay and incentives, to  attract and retain military dentists, but they do not know the extent to  which some of these programs are effective at helping them meet their  recruiting and retention goals. Our prior work on effective strategic  workforce planning principles concluded that agencies should periodically  measure their progress toward meeting human capital goals. These  principles state that measuring the extent that human capital activities  contribute to achieving programmatic goals provides information for  effective oversight by identifying performance shortfalls and appropriate  corrective actions. Further, according to these principles, agencies  should develop use of flexibilities and other human capital strategies that  can be implemented with the resources that can be reasonably expected  to be available, and should consider how these strategies can be aligned  to eliminate gaps. Additionally, Standards for Internal Control in the  Federal Government states that management should monitor internal  control systems, through ongoing monitoring and evaluations. According  to these standards, evaluations should be used to provide feedback on  the effectiveness of ongoing monitoring and should be used to help  design systems and determine effectiveness. The standards also provide  that management should determine the appropriate corrective actions to  address any identified deficiencies upon completing its evaluation.

According to Army, Navy, and Air Force officials, the services have taken  various actions to monitor their recruitment and retention programs. For  example, officials told us that they review recruitment goals,  achievements, and retention rates; conduct workforce planning and  modeling; and participate in recruitment and retention working groups.  Specifically, Army officials stated that they use forecasts from a 5-year  management plan to determine the Army’s recruiting mission and review  its continuation rates to assess retention of dentists. Navy officials told  us that they review annual recruitment goals and track whether they are  meeting those goals on a weekly basis. Air Force officials stated that they  participate in the Medical Accessions Working Group three times per year  to assess ongoing recruitment activities. While the services monitor their  progress toward recruitment and retention goals, they do not know the  extent to which the programs designed to help them meet their goals  affect their ability to recruit and retain dentists because they have not  evaluated their effectiveness.

For example, DOD Directive 1304.21 allows the services to use  accession bonuses to meet their personnel requirements and specifies  that bonuses are intended to influence personnel inventories in specific  situations in which less costly methods have proven inadequate or  impractical. The services have the discretion to issue up to $20,000 as an accession bonus under the AFHPSP—in addition to paying full tuition,  education expenses, and a monthly stipend. In fiscal years 2012  through 2016, the Army and the Navy offered the accession bonus and  generally met their recruitment goals—an achievement that Army officials  credit, in part, to their use of the incentive. Specifically, Army officials told  us that prior to using the bonus in 2009, they were not meeting their  recruitments goals. They also expressed concern that, if they were to  discontinue use of the bonus, they would not be able to meet their current  goals. Conversely, Air Force officials told us that they stopped offering the  bonus in 2012 because the number of AFHPSP applicants had exceeded  the number of AFHPSP positions; the Air Force has continued to meet its  recruiting goals without the use of the bonus. An Air Force official  acknowledged that not offering the bonus could result in their losing  potential applicants to the services that do offer the bonus, but Air Force  officials also recognized that money is not always a deciding factor for  those who choose to serve as a dentist in the military. The uncertainty  described by the Army and Air Force officials demonstrates their lack of  information about what factors motivate individuals to join the military.  Moreover, the differing use of the accession bonus by the two services  with similar outcomes indicates that the services do not know when it is  necessary to use the recruiting tool because they have not evaluated the  effectiveness of this program.

Another bonus the services can offer is the CWSAB, which ranges from  $150,000 for general dentists to $300,000 for comprehensive dentists,  endodontists, prosthodontists, and oral maxillofacial surgeons, to  individuals entering the military as a dentist in a critically short wartime  specialty. While a bonus can be offered to any dental specialty  designated as a critically short wartime specialty, data that we analyzed  indicate that the bonus may be disproportionately effective in recruiting for  these specialties. For example, from fiscal years 2012 through 2016, the  Navy used this type of bonus and was able to meet or exceeded its  recruitment goals for critically short wartime specialty general dentists and  staffed this specialty at between 108 and 122 percent. However, our  analysis of the Navy’s data also found that, even after offering this bonus,  the Navy was unable to recruit any oral surgeons during the same time  period. However, like with the accession bonus, service officials do not  know the extent to which the CWSAB bonus is an effective recruitment  incentive for some or all of the critically short wartime specialties because  they have not evaluated the effectiveness of this program.

In addition, the services offer special pay and incentives, which vary by  specialty, to qualified dentists. Special pay and incentives include  incentive pay, retention bonuses, and board certification pay. Each bonus  and incentive, except board certification pay, requires an additional  service obligation, thus creating a retention tool for the services. The  services and officials from the Office of the ASD(HA) participate in the  Health Professions Incentives Working Group to review recruitment and  retention special pay and incentives and recommends adjustment to  amounts offered as necessary. Service and officials from the Office of the  ASD(HA) told us that there are no ways to evaluate the effectiveness of  these incentives because they cannot account for the emotional or non- monetary decisions that contribute to whether servicemembers stay in the  military, and money is not always an effective incentive for getting people  to train in certain specialties or to continue their service. However, in our  recent review of DOD’s special pay and incentive programs in 2017, we  recommended that DOD take steps to improve the effectiveness of its  special pay and incentive programs. Additionally, in February 2018,  through our review of gaps in DOD’s physician specialties, we  recommended that the services develop targeted and coordinated  strategies to alleviate military physician gaps. An official from the Office  of the ASD(HA) stated that they have started discussing measures with  the services to evaluate the effectiveness of DOD’s medical and dental  recruitment and retention programs, including special pay and incentives.  Additionally, Office of ASD(HA) and service officials stated that they will  begin reviewing the dental special pays and incentives in fiscal year 2019.  Because these reviews are in the early stages, it is too soon to know how  effective they will be in evaluating pay and incentive programs.

Although service officials also told us that they believe their recruitment  and retention programs are effective because they have generally met  their overall recruiting and retention goals, until the services evaluate the  effectiveness of their recruitment and retention efforts, they will not have  the information to know which programs are the most efficient and cost- effective.

section_title: Conclusions
paragraphs: DOD continues to implement several major initiatives to support the  mission of its health system maintaining the medical readiness of  servicemembers while operating as efficiently as possible. The dental  corps plays a critical role in these efforts by ensuring the oral health and  dental readiness of all servicemembers. Ensuring dental readiness  requires, in part, that the services are able to staff dentists adequately  and consistently across DOD’s dental clinics. However, the Army, the  Navy, and the Air Force have not collaborated in their approaches to  staffing dental clinics, and have not developed cross-service staffing  standards for dental clinic staffing. As DOD progresses in its efforts to  implement efficiencies across its Medical Health System and assesses  the scope of medical care to be transferred to the Defense Health  Agency, it could be of benefit to the dental corps to develop cross-service  standards that could result in improvements to the consistency and  efficiency of dental clinic staffing.

In addition to ensuring the appropriate number of dentists at each clinic to  support the dental corps’ mission, recruiting and retaining fully qualified  dentists has been an ongoing challenge for the services. However, the  services have not evaluated whether their existing programs have been  effective at helping them recruit and retain dentists, and therefore do not  know whether they are effectively targeting their resources to address the  most significant recruitment and retention challenges.

section_title: Recommendations for Executive Action
paragraphs: We are making a total of six recommendations, including two to the Army,  two to the Navy, and two to the Air Force. Specifically:  The Secretary of the Army should ensure that the Surgeon General of the  Army Medical Command (1) collaborate with the Navy Bureau of  Medicine and Surgery and the Air Force Medical Service to develop a  common set of planning standards to be used to help determine dental  clinic staffing needs, and (2) incorporate these standards into the Army’s  dental corps staffing model. (Recommendation 1)

The Secretary of the Navy should ensure that the Surgeon General of the  Navy Bureau of Medicine and Surgery (1) collaborate with the Army  Medical Command and the Air Force Medical Service to develop and  implement a common set of planning standards to be used to help  determine dental clinic staffing needs, and (2) incorporate these  standards into the Navy’s dental corps staffing model. (Recommendation  2)

The Secretary of the Air Force should ensure that the Surgeon General of  the Air Force Medical Service (1) collaborate with the Army Medical  Command and the Navy Bureau of Medicine and Surgery to develop and  implement a common set of planning standards to be used to help  determine dental clinic staffing needs, and (2) incorporate these  standards into the Air Force’s dental corps staffing model.  (Recommendation 3)

The Secretary of the Army should ensure that the Surgeon General of the  Army Medical Command evaluates the effectiveness of its recruitment  and retention programs for military dentists, including the need for and  effectiveness of the recruitment and retention incentives currently offered.  (Recommendation 4)

The Secretary of the Navy should ensure that the Surgeon General of the  Navy Bureau of Medicine and Surgery evaluates the effectiveness of its  recruitment and retention programs for military dentists, including the  need for and effectiveness of the recruitment and retention incentives  currently offered. (Recommendation 5)

The Secretary of the Air Force should ensure that the Surgeon General of  the Air Force Medical Service evaluates the effectiveness of its  recruitment and retention programs for military dentists, including the  need for and effectiveness of the recruitment and retention incentives  currently offered. (Recommendation 6)

section_title: Agency Comments
paragraphs: We provided a draft of this report to DOD for review and comment. DOD  did not provide comments. DOD did provide us with technical comments,  which we have incorporated, as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Under Secretary of Defense  for Personnel and Readiness, the Office of the Assistant Secretary of  Health Affairs, the Secretaries of the Army, the Navy, the Air Force, and  the President of the Uniformed Services University of the Health  Sciences. In addition, the report is available at no charge on the GAO  website at http://www.gao.gov.

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

section_title: Appendix I: Military Dentist Accession Programs and Incentives
paragraphs: In addition to the Department of Defense’s (DOD) Armed Forces Health  Professions Scholarship Program, DOD uses several other programs and  incentives to recruit military dentists. Table 3 includes a selection of  DOD’s military dentist accession programs and incentives.

section_title: Appendix II: The Services’ Mechanisms to Monitor Qualifications and Performance of Military Dentists
paragraphs: DOD policy requires that all military dentists must be credentialed and  privileged to practice dentistry. Credentialing is the process of inspecting  and authenticating the documentation to ensure appropriate education,  training, licensure, and experience. Privileging is the corresponding  process that defines the scope and limits of practice for health care  professionals based on their relevant training and experience, current  competence, peer recommendations, and the capabilities of the facility  where they are practicing.

According to officials, the services have developed and implemented  processes to continuously monitor dentist performance in accordance  with DOD policy. According to officials, the services monitor military  dentist performance through On-Going Professional Practice Evaluations  (OPPE) and Focused Professional Practice Evaluations (FPPE). The  OPPE is a continuous evaluation of dentist performance that reviews six  dimensions of performance: (1) patient care, (2) medical knowledge, (3)  professionalism, (4) practice-based learning and improvement, (5)  interpersonal and communication skills, and (6) systems-based practice.  The FPPE is a process of periodic evaluation by the dental clinic of the  specific competence of a dentist performing procedures and  administering care. FPPEs are conducted during a dentist’s initial  appointment, when granting new privileges, or if a question arises about a  dentist’s ability to provide, safe, high quality patient care.

In addition to the performance monitoring required by DOD, according to  officials, the Army and the Air Force have instituted their own  mechanisms for monitoring the quality and performance of their dentists.

Army: According to officials, the Army monitors dental quality through  its quarterly Continuous Quality Management Program. This program  includes the review of data related to records audits, infection control,  radiation protection, utilization management, implant reports, drug  utilization reports, patient safety events, and risk management.  According to officials, these reviews are intended to identify and  address any errors or trends in dental care.

Air Force: According to officials, annually, Air Force dentists must  document that they have reviewed and will follow the Air Force  Medical Service Dental Clinical Practice Guidelines. According to  officials, this ensures that all dentists are following the same standard  of care for dental treatment. Additionally, according to officials, Air  Force dentists participate in a peer review process known as Clinical  Performance Assessment and Improvement. According to officials, in  this process, a licensed peer dentist preferably of the same specialty  reviews the dentist’s practice and procedures. Further, according to  officials, depending on the nature of issues found during the review,  corrective actions—ranging from refresher courses to a loss of license  and credentials—may be taken.

section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Acknowledgments
paragraphs: In addition to the contact named above, Kimberly Mayo, Assistant  Director; Nicole Collier; Alexandra Gonzalez; Amie Lesser; Tida Barakat  Reveley; Rachel Stoiko; John Van Schaik; Lillian Yob; and Elisa Yoshiara  made key contributions to this report.

section_title: Related GAO Products
paragraphs: Defense Health Care: Additional Assessments Needed to Better Ensure  an Efficient Total Workforce. GAO-18-102, Washington, D.C.: Nov. 27,  2018.

Defense Health Care: DOD Should Demonstrate How Its Plan to Transfer  the Administration of Military Treatment Facilities Will Improve Efficiency.  GAO-19-53, Washington, D.C.: Oct. 30, 2018.

Defense Health Care: Expanded Use of Quality Measures Could  Enhance Oversight of Provider Performance. GAO-18-574, Washington,  D.C.: Sept. 17, 2018.

Military Personnel: Additional Actions Needed to Address Gaps in Military  Physician Specialties. GAO-18-77. Washington, D.C.: Feb. 28, 2018.

Defense Health Reform: Steps Taken to Plan the Transfer of the  Administration of the Military Treatment Facilities to the Defense Health  Agency, but Work Remains to Finalize the Plan, GAO-17-791R.  Washington, D.C.: Sept. 29, 2017.

Military Compensation: Additional Actions Are Needed to Better Manage  Special and Incentive Pay Programs. GAO-17-39. Washington, D.C.:  Feb. 3, 2017.

Defense Health Care Reform: DOD Needs Further Analysis of the Size,  Readiness, and Efficiency of the Medical Force. GAO-16-820.  Washington, D.C.: Sept. 21, 2016.

Defense Health Care: Additional Information Needed about Mental Health  Provider Staffing Needs. GAO-15-184. Washington, D.C.: Jan. 30, 2015.

Human Capital: Additional Steps Needed to Help Determine the Right  Size and Composition of DOD’s Total Workforce. GAO-13-470.  Washington, D.C.: May 29, 2013  Defense Health Care: Actions Needed to Help Ensure Full Compliance  and Complete Documentation for Physician Credentialing and Privileging.  GAO-12-31. Washington, D.C.: Dec. 15, 2011.

Military Cash Incentives: DOD Should Coordinate and Monitor Its Efforts  to Achieve Cost-Effective Bonuses and Special Pays. GAO-11-631.  Washington, D.C.: June 21, 2011.

Military Personnel: Enhanced Collaboration and Process Improvements  Needed for Determining Military Treatment Facility Medical Personnel  Requirements. GAO-10-696. Washington, D.C.: Jul. 29, 2010.

Military Personnel: Status of Accession, Retention, and End Strength for  Military Medical Officers and Preliminary Observations Regarding  Accession and Retention Challenges. GAO-09-469R. Washington, D.C.:  Apr. 16, 2009.

Military Personnel: Better Debt Management Procedures and Resolution  of Stipend Recoupment Issues Are Needed for Improved Collection of  Medical Education Debts, GAO-08-612R. Washington, D.C.: Apr. 1, 2008.

Primary Care Professionals: Recent Supply Trends, Projections, and  Valuation of Services. GAO-08-472T. Washington, D.C.: Feb. 12, 2008.

Military Physicians: DOD’s Medical School and Scholarship Program.  GAO/HEHS-95-244. Washington, D.C.: Sept. 29, 1995.

Defense Health Care: Military Physicians’ Views on Military Medicine.  GAO/HRD-90-1. Washington, D.C.: Mar. 22, 1990.

Fast facts: The Army, Navy, and Air Force have implemented common standards for how they determine necessary staffing levels at their health clinics for a number of medical specialties—but haven’t done so for their dental clinics. As a result, DOD dental clinics may not be staffed as efficiently as possible to provide dental care across the military services.

The military services have also struggled to recruit and retain certain types of dental specialists, such as oral surgeons. We recommended that the services develop a common set of dental staffing standards and a process to evaluate recruitment and retention efforts.

Question-summary annotations: questions: question: What are the officials' plan in developing the standards for dental care?
answer: While the services have developed and implemented cross-service staffing standards for 42 medical specialties, according to a key official involved in developing these standards, they currently do not plan to develop a similar set of standards for dental care.

question: What are the benefits of cross-service staffing in standardizing clinic staffing?
answer: Cross-service staffing standards help the services standardize clinic staffing to address the common day-to-day health needs of patients.

question: What is the operating model for clinic staffing required by service officials?
answer: Service officials maintain that they must operate their respective dental clinics autonomously and in a manner that best supports their service-specific needs and unique command structures.
child_questions: question: How are these requirements contrasting DOD's oral health requirements?
answer: However, as oral health requirements for servicemembers are standardized across the Department of Defense (DOD), it is unclear why dental care has been excluded from the staffing standardization effort—especially because the services have implemented cross-service staffing standards for 42 other medical specialties.

questions: question: How do the Army, the Navy, and the Air Force meet their needs for military dentists?
answer: The Army, the Navy, and the Air Force meet their needs for military dentists by recruiting both dental students and fully qualified dentists.

question: How were the goals for recruiting dental students and fully qualified dentists met between fiscal years 2012 and 2016?
answer: The services generally met their recruitment goals for dental students between fiscal years 2012 and 2016, but faced challenges recruiting and retaining fully qualified dentists during that period.
child_questions: question: What were the challenges of recruiting fully qualified dentists for the Army, the Navy and the Air Force respectively?
answer: For example, the Army missed its recruitment goals for fully qualified dentists in all 5 years, the Navy missed its goals in 2 out of 5 years, and the Air Force missed its goals in 3 out of 5 years.
child_questions: question: Where challenges appear to be most pronounced?
answer: These challenges are most pronounced for certain specialties. For example, service data indicate that the Army and the Navy were unable to recruit any oral surgeons, while the Air Force recruited 50 percent of the oral surgeons it needed.

question: What are the reasons for not meeting recruitment goals?
answer: Service officials cited various reasons for not meeting recruitment goals, including the availability of more lucrative careers in the private sector and quality of life concerns associated with military service.

questions: question: How do the services attract and retain military dentists?
answer: The services rely on various programs, including scholarships and special pay and incentives, to attract and retain military dentists, and service officials stated that they monitor their programs by reviewing their goals, among other actions.
child_questions: question: What did GAO find about some services?
answer: However, GAO found that some services continue to provide incentive bonuses for positions that are overstaffed and have met or exceeded recruitment goals, but they do not know whether this is necessary because they have not evaluated the effectiveness of their programs.

question: What are the negative consequences for the services if they do not evaluate their programs?
answer: Without evaluating their programs, the services lack the information necessary to ensure that they are using recruitment and retention incentives effectively and efficiently for attracting and retaining dentists.

questions: question: What was the goal for DOD in modernizing its Military Health System?
answer: DOD has taken steps to modernize its Military Health System to ensure that it operates efficiently.
child_questions: question: What was one step DOD took in realizing this goal?
answer: For example, in September 2013, the Defense Health Agency was created, in part, to implement common clinical and business processes across the services.

question: What are required for the services that are essential to this effort?
answer: Essential to this effort are the services' ability to effectively staff their medical facilities, including the processes used for staffing dental clinics and the services' ability to recruit and retain military dentists.

questions: question: What was the provision included in the Senate Report for GAO?
answer: Senate Report 115-125 included a provision for GAO to review the services' processes for determining requirements for dentists and its programs for recruiting and retaining military dentists, among other things.

question: What did GAO assess about the services?
answer: GAO assessed the extent to which the services (1) use validated dental clinic staffing models that also incorporate cross-service staffing standards, and (2) have recruited and retained military dentists and measured the effectiveness of their recruitment and retention programs.
child_questions: question: What did GAO do apart from assessing service dental clinic models?
answer: GAO assessed service dental clinic models, analyzed recruitment and retention data from fiscal year 2012 through 2016, and interviewed DOD and service officials.