Defense Health Care

Graduate military education programs in military hospitals are the Defense Department's main source of active duty physicians to meet the wartime and peacetime care needs of its 8.2 million military and civilian beneficiaries. In recent years, as their budgets have declined along with overall military personnel strength, the Army, the Navy, and the Air Force have sought to reduce graduate military education enrollment. Such adjustments require care to ensure an appropriate balance between the numbers and types of physician specialists in training, and thus not military deployable, and the numbers of trained specialists available for deployment. As downsizing continues, the military is finding that required graduate military education reductions may entail closing whole programs at selected facilities. In early 1997, the Navy Surgeon General tried but was unsuccessful in closing selected graduate military education programs. This report discusses (1) why the Navy did not accept its council's recommendations for Bethesda graduate military education closures and why its other closure attempts did not succeed, (2) whether the other services already have faced or may face similar experiences, and (3) what improvements may be needed if the services are to successfully make and implement their graduate military education sizing decisions.

GAO noted that: (1) in early 1997, the Navy Surgeon General decided to eliminate 162 GME positions to comply with lower projected wartime requirements and with Department of Defense (DOD) restrictions on the ratio of physicians in training to those deployable; (2) a Navy advisory council, lacking specific guidance but responding to the Navy Surgeon General's indications that GME should occur where active duty personnel are concentrated, recommended that such training be dropped at the Bethesda Medical Center; (3) the Navy Surgeon General, however, instead decided to close some of the Navy's Portsmouth Medical Center's programs following a then newly discussed agreement among DOD and the services' surgeons general to concentrate GME in four geographic locations that included Bethesda and San Diego but not Portsmouth; (4) lacking site selection guidance, the council submitted its recommendation to the Surgeon General without taking account of the agreement, which has never been formalized or acted on by the other services; (5) when announced, the Portsmouth closure decision surprised Navy command and medical center officials there, as well as local congressional representatives; (6) publicized arguments ensued that Portsmouth was as advantageous as Bethesda for concentrating GME and that losing Portsmouth's GME would reduce trainee-provided health care to active duty personnel and other beneficiaries and would harm Navy readiness; (7) although it was unsuccessful, the Surgeon General's office tried justifying the decision and later withdrew it for further study; (8) shortly thereafter and for the same ends, the Army Surgeon General's office sought to eliminate the 64 GME positions at the William Beaumont Medical Center in El Paso, Texas, also without site selection guidance and likewise failing to involve those who were affected; (9) while the Air Force also foresees the need for GME program closures, it has not yet attempted to make them; (10) but in the absence of closure policies and criteria and judging from the Navy's and Army's closure attempt experiences, GAO has no reason to believe that the Air Force would be any more successful in bringing about required GME program adjustments; and (11) while not a direct parallel to DOD GME with its readiness dimension, private-sector medical schools and hospitals have been downsizing their GME programs and in doing so have documented success factors that may provide a useful reference for DOD in developing guidance for its future sizing efforts.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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