Objective:
Our objective was to determine whether DoD is meeting access to care standards for acute and routine appointments at selected military treatment facilities.
Background:
Federal regulations establish access to care standards for the Military Health System, including providing patients an appointment to visit a provider within 7 days for a routine appointment and 24 hours for an urgent appointment. Assistant Secretary of Defense (Health Affairs) guidance states that DoD beneficiaries must be offered routine and urgent appointments within the established standards. When health care is not available within access to care standards at the MTF, beneficiaries can receive health care outside of the MTF. The Defense Health Agency’s (DHA) access to care metrics measure the ability of the MTFs to meet the standard of urgent and routine appointments.
According to DoD guidance, the DHA Director coordinates with the Military Departments regarding administration of MTFs. However, public law changed the DHA’s responsibilities regarding the MTFs. Beginning October 1, 2018, the DHA Director will be responsible for the administration of each MTF, and the Secretary of Defense, in consultation with the Secretaries of the Military Departments, will maintain the MTFs.
In the Preliminary Draft Interim Report delivered on March 31, 2017, the DoD confirmed the Secretary of Defense’s decision to implement a new model to address the requirements listed in the law. The Department will submit a final report to Congress by June 30, 2018.
Finding:
The DoD did not consistently meet the access to care standards for urgent and routine appointments at selected MTFs. Based on DHA metrics, three of the seven MTFs we visited, Irwin Army Community Hospital at Fort Riley, Kansas; Naval Hospital Pensacola, Pensacola, Florida; and Naval Health Clinic Hawaii at Joint Base Pearl Harbor, Hickam, Hawaii met access to care standards for routine and urgent appointments and one MTF, Tripler Army Medical Center, Honolulu, Hawaii, met access to care standards for 4 of 5 months between January and May 2017.
However, three Air Force MTFs—U.S. Air Force Hospital Langley at Joint Base Langley-Eustis, Virginia; David Grant U.S. Air Force Medical Center at Travis Air Force Base, California; and MacDill Air Force Base Clinic at MacDill Air Force Base, Florida—did not consistently meet access to care standards. For example, in February 2017, U.S. Air Force Hospital Langley did not meet the 7-day routine appointment metric by 15.8 days (226 percent). Additionally, in March 2017, David Grant U.S. Air Force Medical Center did not meet the 1-day urgent appointment metric by 7.2 days (720 percent).
The Air Force MTFs did not meet beneficiary demand for appointments because the Air Force Surgeon General:
- assigned a higher number of patients per health care provider compared to the Army and Navy;
- did not establish policy to consistently decrease the number of appointments per provider to compensate for their other duties (except for flight commanders);
- did not pay comparable salaries for civilian nursing personnel; and
- did not have authority to direct Air Force medical personnel.
As a result, the 105,000 MHS beneficiaries enrolled at the three Air Force MTFs we visited may not have received the care they needed, and may have been at risk of increased health complications due to longer wait times. In March 2017, beneficiaries waited as long as 8.2 days on average for an urgent appointment at David Grant U.S. Air Force Medical Center and, in February 2017, beneficiaries waited as long as 22.8 days on average for a routine appointment at U.S. Air Force Hospital Langley. Because of the DHA’s oversight and assumption of expanded responsibilities for MTFs, we made recommendations to the DHA Director instead of the Air Force Surgeon General.
Recommendations:
We recommend that the DHA Director establish a standard method across the Military Departments for calculating the number of patients assigned to each provider and establish a standard method for decreasing the number of appointments per provider based on their additional duties. Additionally, the DHA Director should convene a working group with personnel from the Military Departments’ Surgeons General and the Air Force Personnel Center to conduct a review to determine if position descriptions and pay grades for civilian medical personnel assigned to MTFs are consistent, and consider standardizing position descriptions and pay grades across the Military Departments. Finally, we recommend that the DHA Director, in coordination with the Air Force Surgeon General, develop a plan outlining how the DHA will assume authority, direction, and control over Air Force MTFs to make changes necessary to improve access to care and hold MTF commanders accountable when the MTFs do not meet access to care standards.
Management Actions Taken:
The DHA Director agreed with our finding and recommendations. The Director agreed to implement additional standard business rules to calculate empanelment sizes to reduce variances at MTFs and establish a standard method for decreasing the number of appointments that are scheduled for certain providers based on those providers’ additional assigned duties. Additionally, the Director agreed to convene a working group to review position descriptions and pay grades. Finally, the Director agreed to develop a plan on how the DHA will hold MTF commanders accountable for meeting access to care standards. Therefore, these recommendations are resolved but remain open. We will close the recommendations once we verify that the DHA has implemented the planned corrective actions.
The Air Force Surgeon General provided comments and requested technical changes to the report, some of which we incorporated in the final report and others we did not. See the Finding section for a summary of those comments and our response.
This report is a result of Project No. D2017-D000CJ-0104.000.