Military Health Care: Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns

What GAO Found

The Defense Health Agency (DHA) within the Department of Defense (DOD) has established processes for preventing and responding to quality and safety concerns about individual providers delivering health care in military treatment facilities (MTF). Specifically, DHA’s August 2019 policy standardized processes for managing health care quality in the Military Health System, which superseded the policies of each of the military services (Air Force, Army, and Navy). These processes include 1) initial and ongoing monitoring of providers; 2) taking action to deny, limit, or remove individual providers’ ability to practice, known as adverse privileging action; and 3) reviewing the care delivered by individual providers involved in certain patient safety events, known as potentially compensable event reviews.

For example, DHA policy establishes requirements for taking adverse privileging actions against a provider that either limit the care a provider is allowed to deliver at a facility or prevent the provider from delivering care altogether, when warranted. In particular, DHA policy specifies that the provider’s privileges should be placed in summary suspension—a temporary removal of all or a portion of the provider’s privileges—while a peer conducts an investigation of the concerns. DHA policy also specifies that summary suspensions lasting greater than 30 days, as well as any final adverse privileging actions, must be reported to the National Practitioner Data Bank (NPDB). The NPDB is an electronic repository that collects and releases information on certain adverse actions and medical malpractice payments related to providers. According to DOD officials, 27 DOD providers were reported to the NPDB for a summary suspension lasting greater than 30 days between February 1, 2020—when this requirement was implemented—and September 30, 2020.

Why GAO Did This Study

DHA supports the delivery of health care to servicemembers and their families throughout the Military Health System. As in all health care delivery settings, concerns may arise about the quality and safety of care delivered by individual health care providers at MTFs. For example, patient safety events—incidents that could have resulted or did result in harm to a patient—may occur during the course of providing health care services and may raise questions about the quality and safety of care delivered. DHA is responsible for ensuring the quality and safety of health care delivered by military and civilian health care providers, including contractors, through its clinical quality management program.

The National Defense Authorization Act for Fiscal Year 2020 included a provision for GAO to review aspects of DOD’s clinical quality management program, including its processes for reviewing the quality and safety of providers’ care. This report describes DHA’s processes for preventing and responding to quality and safety concerns about individual health care providers at MTFs. In future work, GAO will examine the implementation of these processes at MTFs.

GAO reviewed documentation that contains policy and guidance for these processes, including DHA’s August 2019 procedure manual for managing clinical quality management in the Military Health System. GAO also interviewed officials from DHA and each of the military services. We provided a draft of this report to DOD for review and comment. DOD concurred with our report and provided technical comments, which we incorporated as appropriate.

For more information, contact Sharon M. Silas at(202)512-7114 or Silass@gao.gov.

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    Five local members of the violent Mara Salvatrucha (MS-13) international street gang are set to appear in court following charges of conspiracy and murder in aid of racketeering, announced Acting Assistant Attorney General Brian C. Rabbitt of the Justice Department’s Criminal Division and U.S. Attorney Ryan K. Patrick of the Southern District of Texas.
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    Robert F. Smith, the Chairman and Chief Executive Officer of a San Francisco based private equity company, entered into a Non-Prosecution Agreement (the agreement) with the Department of Justice, for his involvement from 2000 through 2015 in an illegal scheme to conceal income and evade millions in taxes by using an offshore trust structure and offshore bank accounts, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Tax Division, U.S. Attorney David L. Anderson for the Northern District of California, and Chief of Internal Revenue Service (IRS) Criminal Investigation Jim Lee. In that agreement, Smith admits his involvement in the illegal scheme and agrees to cooperate with ongoing investigations and to pay back taxes and penalties in full. 
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  • Private Health Coverage: Results of Covert Testing for Selected Offerings
    In U.S GAO News
    GAO performed 31 covert tests to selected sales representatives and stated that we had pre-existing conditions, such as diabetes or heart disease, and we requested coverage for these conditions to see if the sales representative directed GAO's undercover agents to a comprehensive Patient Protection and Affordable Care Act (PPACA)-compliant plan, or a PPACA-exempt plan that does not cover what we requested. As part of these tests, GAO gauged whether sales representatives engaged in potentially deceptive practices, such as making false or misleading statements about coverage or omitting material information about coverage. The results of the covert tests ranged from sales representatives appropriately explaining to GAO's undercover agents that a PPACA-exempt plan would not cover the pre-existing condition the undercover agents stated that they had, to engaging in potentially deceptive marketing practices that misrepresented or omitted information about the products they were selling. Specifically, in 21 of 31 covert tests, the sales representative appropriately referred undercover agents to a PPACA-compliant plan. In two of 31 covert tests, the sales representatives did not appear to engage in deceptive marketing practices but were not always consistent or clear in their explanation of the type of coverage and plans they were selling. In the remaining eight of 31 covert tests, the sales representatives engaged in potentially deceptive marketing practices, such as claiming the pre-existing condition was covered when the health plan documents GAO received after purchase said otherwise. GAO plans to refer these eight cases of potential deceptive marketing practices to the Federal Trade Commission (FTC) and corresponding state insurance commissioners' offices for follow-up as appropriate. Millions of Americans obtain health insurance coverage in the individual market, which consists mainly of private plans sold directly to consumers without access to group coverage. While generally regulated by states, starting in 2014, PPACA established a number of new federal requirements for the individual health insurance market. For example, PPACA prohibited insurers from excluding coverage or charging higher premiums for pre-existing conditions and required that individual market plans cover a set of essential health benefits, including coverage for mental health and substance abuse disorder services, prescription drugs, and maternity and newborn care. Certain types of health coverage arrangements that can be sold directly to consumers do not have to comply with some or all of PPACA's individual market requirements and, as a result, may be less expensive, but also offer more limited benefits compared to PPACA-compliant plans. Recent changes to federal law and regulations could result in the increased use of PPACA-exempt health coverage arrangements as alternatives to PPACA-compliant plans in the individual market. For example, in 2018, federal regulations expanded the availability of short term, limited duration insurance (STLDI) plans, a type of PPACA-exempt arrangement. In addition, starting January 1, 2019, individuals who fail to maintain "minimum essential coverage," as required by PPACA, no longer face a tax penalty. Further, the devastating economic effects of the Coronavirus Disease 2019 (COVID-19) pandemic could create additional demand for affordable health coverage, including PPACA-exempt plans.  With these changes, and because of their lower relative costs, PPACA-exempt health coverage arrangements may be attractive to consumers, particularly those who find it difficult to afford PPACA-compliant plans. However, such arrangements generally do not need to follow PPACA's requirement that plans in the individual market be presented to consumers in defined categories outlining the extent to which they are expected to cover medical care. As a result, depending on how they are marketed and sold, PPACA-exempt arrangements could present risks for consumers, if, for example, they buy them mistakenly believing that coverage is as comprehensive as for PPACA-compliant plans. GAO was asked to obtain insights on the marketing and sales practices of insurance sales representatives who sell PPACA-exempt plans. In this report, GAO describes the results of covert tests we conducted involving selected sales representatives, when contacted by individuals stating that they had pre-existing conditions. In this regard, GAO agents performed a number of covert tests (i.e., undercover phone calls) from November 2019 through January 2020 posing as individuals needing to purchase health insurance to cover pre-existing conditions. GAO also discussed the marketing and oversight of PPACA-exempt arrangements with senior officials from federal agencies, including the FTC, and Centers of Medicare and Medicaid Services (CMS) within the Department of Health and Human Services (HHS), as well as the National Association of Insurance Commissioners (NAIC)5. GAO provided a draft of this product to FTC, HHS, and NAIC for review and comment. FTC, HHS, and NAIC provided technical comments, which GAO incorporated as appropriate. HHS provided additional written comments on a draft of this report. For more information, contact Seto Bagdoyan at (202)-6722 or bagdoyans@gao.gov.
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    Today, the Department of Justice announced Standards for Certification that will be used by credentialing bodies so they can begin certifying thousands of law enforcement agencies over the next three months. The Standards of Certification are a result of President Trump’s June Executive Order 13929, Safe Policing for Safe Communities.
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  • Science & Tech Spotlight: Air Quality Sensors
    In U.S GAO News
    Why This Matters Air quality sensors are essential to measuring and studying pollutants that can harm public health and the environment. Technological improvements have led to smaller, more affordable sensors as well as satellite-based sensors with new capabilities. However, ensuring the quality and appropriate interpretation of sensor data can be challenging. The Technology What is it? Air quality sensors monitor gases, such as ozone, and particulate matter, which can harm human health and the environment. Federal, state, and local agencies jointly manage networks of stationary air quality monitors that make use of sensors. These monitors are expensive and require supporting infrastructure. Officials use the resulting data to decide how to address pollution or for air quality alerts, including alerts during wildfires or on days with unhealthy ozone levels. However, these networks can miss pollution at smaller scales and in rural areas. They generally do not measure air toxics—more localized pollutants that may cause cancer and chronic health effects—such as ethylene oxide and toxic metals. Two advances in sensor technologies may help close these gaps. First, newer low-cost sensors can now be deployed virtually anywhere, including on fences, cars, drones, and clothing (see fig. 1). Researchers, individuals, community groups, and private companies have started to deploy these more affordable sensors to improve their understanding of a variety of environmental and public health concerns. Second, federal agencies have for decades operated satellites with sensors that monitor air quality to understand weather patterns and inform research. Recent satellite launches deployed sensors with enhanced air monitoring capabilities, which researchers have begun to use in studies of pollution over large areas. Figure 1. There are many types of air quality sensors, including government-operated ground-level and satellite-based sensors, as well as low-cost commercially available sensors that can now be used on a variety of platforms, such as bicycles, cars, trucks, and drones. How does it work? Low-cost sensors use a variety of methods to measure air quality, including lasers to estimate the number and size of particles passing through a chamber and meters to estimate the amount of a gas passing through the sensor. The sensors generally use algorithms to convert raw data into useful measurements (see fig. 2). The algorithms may also adjust for temperature, humidity and other conditions that affect sensor measurements. Higher-quality devices can have other features that improve results, such as controlling the temperature of the air in the sensors to ensure measurements are consistent over time. Sensors can measure different aspects of air quality depending on how they are deployed. For example, stationary sensors measure pollution in one location, while mobile sensors, such as wearable sensors carried by an individual, reflect exposure at multiple locations. Satellite-based sensors generally measure energy reflected or emitted from the earth and the atmosphere to identify pollutants between the satellite and the ground. Some sensors observe one location continuously, while others observe different parts of the earth over time. Multiple sensors can be deployed in a network to track the formation, movement, and variability of pollutants and to improve the reliability of measurements. Combining data from multiple sensors can increase their usefulness, but it also increases the expertise needed to interpret the measurements, especially if data come from different types of sensors. Figure 2. A low-cost sensor pulls air in to measure pollutants and stores information for further study. How mature is it? Sensors originally developed for specific applications, such as monitoring air inside a building, are now smaller and more affordable. As a result, they can now be used in many ways to close gaps in monitoring and research. For example, local governments can use them to monitor multiple sources of air pollution affecting a community, and scientists can use wearable sensors to study the exposure of research volunteers. However, low-cost sensors have limitations. They operate with fewer quality assurance measures than government-operated sensors and vary in the quality of data they produce. It is not yet clear how newer sensors should be deployed to provide the most benefit or how the data should be interpreted. Some low-cost sensors carry out calculations using artificial intelligence algorithms that the designers cannot always explain, making it difficult to interpret varying sensor performance. Further, they typically measure common pollutants, such as ozone and particulate matter. There are hundreds of air toxics for which additional monitoring using sensors could be beneficial. However, there may be technical or other challenges that make it impractical to do so. Older satellite-based sensors typically provided infrequent and less detailed data. But newer sensors offer better data for monitoring air quality, which could help with monitoring rural areas and pollution transport, among other benefits. However, satellite-based sensor data can be difficult to interpret, especially for pollution at ground level. In addition, deployed satellite-based sensor technologies currently only measure a few pollutants, including particulate matter, ozone, sulfur dioxide, nitrogen dioxide, formaldehyde, and carbon monoxide. Opportunities Improved research on health effects. The ability to track personal exposure and highly localized pollution could improve assessments of public health risks. Expanded monitoring. More dense and widespread monitoring could help identify pollution sources and hot spots, in both urban and rural areas. Enhanced air quality management. Combined measurements from stationary, mobile, and satellite-based sensors can help officials understand and mitigate major pollution issues, such as ground-level ozone and wildfire smoke. Community engagement. Lower cost sensors open up new possibilities for community engagement and citizen science, which is when the public conducts or participates in the scientific process, such as by making observations, collecting and sharing data, and conducting experiments. Challenges Performance. Low-cost sensors have highly variable performance that is not well understood, and their algorithms may not be transparent. Low-cost sensors operated by different users or across different locations may have inconsistent measurements. Interpretation. Expertise may be needed to interpret sensor data. For example, sensors produce data in real time that may be difficult to interpret without health standards for short-term exposures. Data management. Expanded monitoring will create large amounts of data with inconsistent formatting, which will have to be stored and managed. Alignment with needs. Few of the current low-cost and satellite-based sensors measure air toxics. In addition, low-income communities, which studies show are disproportionally harmed by air pollution, may still face challenges deploying low-cost sensors. Policy Context and Questions How can policymakers leverage new opportunities for widespread monitoring, such as citizen science, while also promoting appropriate use and interpretation of data? How can data from a variety of sensors be integrated to better understand air quality issues, such as environmental justice concerns, wildfires, and persistent ozone problems? How can research and development efforts be aligned to produce sensors to monitor key pollutants that are not widely monitored, such as certain air toxics? For more information, contact Karen Howard at (202) 512-6888 or HowardK@gao.gov.
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    The Justice Department today filed a lawsuit against the Village of Hinsdale, Illinois, alleging disability discrimination in violation of the Fair Housing Act.  
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  • Retirement Security: DOL Could Better Inform Divorcing Parties About Dividing Savings
    In U.S GAO News
    Although more than one-third of adults aged 50 or older have experienced divorce, few people seek and obtain a Qualified Domestic Relations Order (QDRO), according to large plan sponsors GAO surveyed. A QDRO establishes the right of an alternate payee, such as a former spouse, to receive all or a portion of the benefits payable to a participant under a retirement plan upon separation or divorce. There are no nationally representative data on the number of QDROs, but plans and record keepers GAO interviewed and surveyed reported that few seek and obtain QDROs. For example, the Pension Benefit Guaranty Corporation administered retirement benefits to about 1.6 million participants, and approved about 16,000 QDROs in the last 10 years. GAO's analysis of other survey data found about one-third of those who experienced a divorce from 2008 to 2016 and reported their former spouse had a retirement plan also reported losing a claim to that spouse's benefits. Many experts stated that some people—especially those with lower incomes—face challenges to successfully navigating the process for obtaining a QDRO, including complexity and cost. Individuals seeking a QDRO may be charged fees for preparation and review of draft orders before they are qualified as QDROs and, according to experts GAO interviewed, these fees vary widely. These experts cited concerns about QDRO review fees that they said in some cases were more than twice the amount of typical fees, and said they may discourage some from pursuing QDROs. Department of Labor (DOL) officials said the agency generally does not collect information on QDRO fees. Exploring ways to collect and analyze information from plans on fees could help DOL ensure costs are reasonable. Divorcing parties who pursue QDROs often had orders not qualified due to lacking basic information, according to plans and record keepers we surveyed (see figure). Plan Administrators and Record Keepers Reported Reasons for Not Qualifying a Domestic Relations Order (DRO) DOL provides some information to help divorcing parties pursue QDROs. However, many experts cited a lack of awareness about QDROs by the public and said DOL could do more to make resources available to divorcing parties. Without additional outreach by DOL, divorcing parties may spend unnecessary time and resources drafting orders that are not likely to be qualified, resulting in unnecessary expenditures of time and money. A domestic relations order (DRO) is a court-issued judgment, decree, or order that, when qualified by a retirement plan administrator, can divide certain retirement benefits in connection with separation or divorce and as such provide crucial financial security to a former spouse. DOL has authority to interpret QDRO requirements. GAO was asked to review the process for obtaining QDROs. This report examines what is known about (1) the number of QDRO recipients, (2) the fees and other expenses for processing QDROs, and (3) the reasons plans do not initially qualify DROs and the challenges experts identify regarding the QDRO process. To conduct this work, GAO analyzed available data, and a total of 14 responses from two surveys of large private sector plans and account record keepers, and interviewed 18 experts including practitioners who provide services to divorcing couples. GAO is recommending that DOL (1) explore ways to collect information on QDRO-related fees charged to participants or alternate payees, and (2) take steps to ensure information about the process for obtaining a QDRO is accessible. DOL generally agreed with our recommendations. For more information, contact Kris Nguyen at (202) 512-7215 or NguyenTT@gao.gov.
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