Military Base Realignments and Closures: Impact of Terminating,
Relocating, or Outsourcing the Services of the Armed Forces
Institute of Pathology (09-NOV-07, GAO-08-20).
The 2005 Base Realignment and Closure (BRAC) provision required
the Department of Defense (DOD) to close the Armed Forces
Institute of Pathology (AFIP). GAO was asked to address the
status and potential impact of implementing this BRAC provision.
This report discusses (1) key services AFIP provides to the
military and civilian communities; (2) DOD's plans to terminate,
relocate, or outsource services currently provided by AFIP; and
(3) the potential impacts of disestablishing AFIP on military and
civilian communities. New legislation requires DOD to consider
this GAO report as it develops its plan for the reorganization of
AFIP. GAO reviewed DOD's plans, analysis, and other relevant
information, and interviewed officials from the public and
private sectors.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-08-20
ACCNO: A78112
TITLE: Military Base Realignments and Closures: Impact of
Terminating, Relocating, or Outsourcing the Services of the Armed
Forces Institute of Pathology
DATE: 11/09/2007
SUBJECT: Army facilities
Army personnel
Base closures
Base realignments
Disease detection or diagnosis
Federal facility relocation
Health care services
Military personnel
Physicians
Program evaluation
Program management
Program implementation
DOD Base Realignment and Closure Program
******************************************************************
** This file contains an ASCII representation of the text of a **
** GAO Product. **
** **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced. Tables are included, but **
** may not resemble those in the printed version. **
** **
** Please see the PDF (Portable Document Format) file, when **
** available, for a complete electronic file of the printed **
** document's contents. **
** **
******************************************************************
GAO-08-20
* [1]Results in Brief
* [2]Background
* [3]Role of AFIP
* [4]DOD Examines AFIP's Future Role
* [5]AFIP's Key Services Include Consultation, Education, and Res
* [6]Providing Consultations Is AFIP's Primary Mission, and DOD I
* [7]AFIP Provides Varied Educational Services, Used Primarily by
* [8]AFIP's Research Benefits DOD, VA, and Civilians
* [9]DOD Has Specific Plans to Terminate Most Services Currently
* [10]Most of AFIP's Services Will Be Terminated, but Some Will Be
* [11]Planned Implementation to be Completed by 2011
* [12]Closing AFIP May Have Minimal Effect, but Management Strateg
* [13]DOD, VA, and Civilian Physicians May Be Able to Obtain Key S
* [14]DOD Faces Challenges in Ensuring That Military Physicians' A
* [15]Research Could Be Affected Depending on How DOD Plans to Pop
* [16]Conclusions
* [17]Recommendations for Executive Action
* [18]Agency Comments and Our Evaluation
* [19]Appendix I: Scope and Methodology
* [20]Appendix II: Maps of the Armed Forces Institute of Pathology
* [21]Appendix III: Description of Services Performed by the Armed
* [22]Appendix IV: Comments from the Department of Defense
* [23]Appendix V: Comments from the Department of Veterans Affairs
* [24]Appendix VI: GAO Contact and Staff Acknowledgments
* [25]GAO Contact
* [26]Acknowledgments
* [27]Related GAO Products
* [28]Order by Mail or Phone
* [29]PDF6-Ordering Information.pdf
* [30]GAO's Mission
* [31]Obtaining Copies of GAO Reports and Testimony
* [32]Order by Mail or Phone
* [33]To Report Fraud, Waste, and Abuse in Federal Programs
* [34]Congressional Relations
* [35]Public Affairs
Report to the Committee on Health, Education, Labor, and Pensions, U.S.
Senate
United States Government Accountability Office
GAO
November 2007
MILITARY BASE REALIGNMENTS AND CLOSURES
Impact of Terminating, Relocating, or Outsourcing the Services of the
Armed Forces Institute of Pathology
GAO-08-20
Contents
Letter 1
Results in Brief 3
Background 6
AFIP's Key Services Include Consultation, Education, and Research That
Benefit DOD, VA, and Civilian Communities 8
DOD Has Specific Plans to Terminate Most Services Currently Provided by
AFIP and Is Developing Plans to Relocate the Others 16
Closing AFIP May Have Minimal Effect, but Management Strategy Is Important
to Address Key Challenges 23
Conclusions 31
Recommendations for Executive Action 32
Agency Comments and Our Evaluation 33
Appendix I Scope and Methodology 37
Appendix II Maps of the Armed Forces Institute of Pathology's (AFIP) 2006
Consultations 39
Appendix III Description of Services Performed by the Armed Forces
Institute of Pathology (AFIP) 42
Appendix IV Comments from the Department of Defense 46
Appendix V Comments from the Department of Veterans Affairs 48
Appendix VI GAO Contact and Staff Acknowledgments 51
Related GAO Products 52
Tables
Table 1: Number and Percentage of AFIP Consultations for Customers, 2005
and 2006 10
Table 2: Consultation Outcomes Where an Initial Diagnosis Was Provided,
for 2006 11
Table 3: Examples of AFIP's Research Projects 15
Table 4: Services Currently Performed by AFIP That Are to Be Retained and
Relocated, or Established, or Are Awaiting Final Decisions 20
Figures
Figure 1: DOD's Proposed Timeline for BRAC Implementation Pertaining to
AFIP 22
Figure 2: AFIP's DOD Consultations for 2006 39
Figure 3: AFIP's VA Consultations for 2006 40
Figure 4: AFIP's Civilian Consultations for 2006 41
Abbreviations
CBP: Customs and Border Protection:
DHS: Department of Homeland Security:
DOD: Department of Defense:
EAA: Export Administration Act:
EXBS: Export Control and Related Border Security Assistance:
Program:
FBI: Federal Bureau of Investigation:
G8: Group of Eight:
IAEA: International Atomic Energy Agency:
ICE: Immigration and Customs Enforcement:
ICP: International Counterproliferation Program:
INECP: International Nonproliferation Export Control Program:
NPT: Non-Proliferation Treaty:
NSG: Nuclear Suppliers Group:
OFAC: Office of Foreign Assets Control:
PSI: Proliferation Security Initiative:
UAE: United Arab Emirates:
UN: United Nations:
WMD: weapons of mass destruction:
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.
United States Government Accountability Office
Washington, DC 20548
November 9, 2007
The Honorable Edward M. Kennedy
Chairman
The Honorable Michael B. Enzi
Ranking Member Committee on Health, Education, Labor, and Pension
United States Senate
On May 13, 2005, the Department of Defense (DOD) recommended closing the
Armed Forces Institute of Pathology^1 (AFIP)--an agency within DOD--as
part of the Base Realignment and Closure (BRAC) process.^2 This would
require that the pathology services currently provided by AFIP be
discontinued, transferred to other parts of DOD or elsewhere, or
outsourced to the civilian community. AFIP provides pathology
expertise--which is based on laboratory analyses of tissue or other
specimens to diagnose diseases or other medical conditions--to military
and civilian physicians and maintains a rich and comprehensive catalog of
pathology material such as tissue specimens, referred to as the National
Pathology Repository.^3 In addition to providing services to DOD, AFIP
provides its expertise to other physicians such as those working at the
Department of Veterans Affairs (VA) and it has statutory authority to
provide pathology services to civilian physicians.^4 According to the
College of American Pathologists (CAP) and other pathology organizations,
AFIP is relied upon by its customers as a definitive consult on the most
difficult-to-diagnose cases and through its research and training has
advanced the knowledge and competency of the medical profession.
^1Pathology is the study of bodily changes due to disease, injury, or
other medical conditions, and it can lead to advancements in diagnosis and
treatment.
^2Through the BRAC process, DOD can recommend closing or realigning
military facilities to reorganize its structure and facilitate new ways of
doing business. These recommendations are reviewed by the independent BRAC
Commission. The BRAC Commission then issues its recommendations to the
President. After the President approves the recommendations, they are
forwarded to Congress, which has 45 days to disapprove the recommendations
on an all-or-none basis; if Congress does not act, the recommendations
become binding.
^3The National Pathology Repository, located at AFIP, stores material
coded by pathologic diagnosis. The National Pathology Repository currently
stores over 2.8 million cases coded since 1917. The material includes
written records and over 50 million microscopic slides, 30 million
paraffin tissue blocks, and 12 million preserved wet tissue specimens.
Cases represent the entire spectrum of human disease, including both
sexes, all races/ethnicities, all ages, as well as animal disease, and
come from contributors worldwide. Hereafter, the National Pathology
Repository is referred to as the repository.
In accordance with the BRAC statute, DOD must complete closure and
realignment actions within 6 years from the time the recommendations were
forwarded to Congress, which for the 2005 BRAC provisions is September 15,
2011.^5 In light of the BRAC provision specific to AFIP,^6 the Senate
Committee on Health, Education, Labor, and Pensions requested an analysis
of the impact of disestablishing, relocating, or outsourcing AFIP's key
services due to concerns that this would affect the ability of military
and civilian communities to obtain high-quality pathology services. In
this report, we discuss (1) the key services AFIP provides to the military
and civilian communities; (2) DOD's plans to terminate, relocate, or
outsource services currently provided by AFIP; and (3) the potential
impacts of disestablishing AFIP on military and civilian communities.
To accomplish these objectives, we reviewed recent reports describing
AFIP's services and business practices, including a previous GAO report on
AFIP's business plan,^7 as well as those conducted by the Army Audit
Agency and BearingPoint--a consulting company that fulfilled a contract
from the Army Surgeon General to review AFIP. We also reviewed other
documents and legislation pertaining to AFIP and the BRAC provision,
including business plans and data related to analysis that led to
BRAC-related decisions. Additionally, we obtained data from AFIP to
describe key services it provides and we determined the data to be
sufficiently reliable for the purposes of this report. We also interviewed
officials from AFIP, VA, the American Registry of Pathology (ARP), and
pathology associations such as CAP to collect information on the services
that AFIP provides. Within DOD, we interviewed officials from the Offices
of the Surgeons General of the Army, Navy, and Air Force; the Office of
the Assistant Secretary of Defense for Health Affairs (ASD(HA)); the
TRICARE Management Activity; the Office of the Deputy Under Secretary of
Defense (Installations and Environment); the Uniformed Services University
of the Health Sciences (USUHS)--a military medical training and research
institution;^8 and the Office of the General Counsel. We also interviewed
pathologists from DOD military treatment facilities (MTF) and VA medical
centers. Finally, to assess the potential impacts of terminating AFIP and
relocating services, we interviewed officials as mentioned above, civilian
pathologists from major medical centers, as well as representatives from
pathology and radiology associations such as ARP, CAP, the American
Society for Investigative Pathology, the Association of Pathology Chairs,
the American College of Radiology, and the Canadian Association of
Radiologists. We conducted our work from March 2007 through November 2007
in accordance with generally accepted government auditing standards.
Further details on our scope and methodology are described in appendix I.
^4See 10 U.S.C. S 176(b)(1)(A).
^5See Defense Base Closure and Realignment Act of 1990, Pub. L. No.
101-510, S 2904(a)(5), codified as amended at 10 U.S.C. S 2687, note.
^6In this report, we refer to this as the BRAC provision.
^7GAO, Armed Forces Institute of Pathology: Business Plan's Implementation
Is Unlikely to Achieve Expected Financial Benefits and Could Reduce
Civilian Role, [36]GAO-05-615 (Washington, D.C.: June 30, 2005).
Results in Brief
AFIP pathologists perform three key services--diagnostic consultations,
education, and research--that benefit military and civilian communities.
AFIP pathologists provide diagnostic consultations when physicians--that
is, clinicians or general pathologists--at DOD, VA, or civilian medical
centers cannot make a diagnosis or are unsure of their initial diagnosis.
In 2006, AFIP provided over 40,000 diagnostic consultations, almost half
of which were for DOD. AFIP's remaining consultations were nearly equally
divided between VA and civilian physicians. AFIP's educational services
include courses, texts, and distance learning activities that draw upon
pathology material from the repository. AFIP's educational services train
physicians in diagnosing the most difficult-to-diagnose diseases. While
DOD, VA, and civilian physicians use AFIP's educational services, civilian
physicians use AFIP's educational services more extensively than military
physicians. Regarding its research services, AFIP pathologists work
individually and in partnership with other federal and private researchers
using material from the repository to conduct research applicable to
military operations, as well as to diagnose and treat diseases affecting
military and civilian health. For example, pathologists from AFIP were
able to reconstruct the genome of the virus that caused the 1918 Spanish
Flu pandemic from material in the repository. This discovery has provided
a better understanding of how an avian flu epidemic can become deadly to
humans, which in turn has affected current strategies to address the
potential of pandemic flu.
^8USUHS consists of a military medical school and graduate nursing school
and provides doctoral and masters degrees in biomedical and public health.
It is affiliated with major military teaching hospitals, such as Walter
Reed Army Medical Center and Wilford Hall Medical Center. Additionally,
USUHS is affiliated with the Washington Hospital Center, a major civilian
teaching hospital.
In accordance with the BRAC provision, DOD plans to terminate most
services currently provided by AFIP and is developing plans to relocate or
outsource other services. Specifically, DOD plans to outsource its
second-opinion and some initial consultations to the private sector
through a new Program Management Office (PMO), which was required to be
established by the BRAC provision. DOD has not determined whether it would
allow VA to obtain diagnostic consultations through the PMO. DOD plans to
retain and relocate only two training programs currently offered by
AFIP--the enlisted histology technician training and the DOD Veterinary
Pathology Residency Program. DOD also plans to halt AFIP's research and
realign the repository, which is AFIP's primary research resource. The
BRAC provision provided DOD with flexibility to retain services that were
not addressed in the provision. In accordance with this statutory
authority, the ASD(HA) has retained four additional AFIP services and is
considering whether to retain six others. DOD planned to begin
implementation of the BRAC provision in July 2007 and to complete action
by September 2011. However, statutory requirements prevent DOD from
reorganizing or relocating AFIP functions until after DOD has submitted
detailed plans and timetables for the proposed reorganization and
relocation to the House and Senate Appropriations and Armed Services
Committees.^9 Once the plan has been submitted, DOD can resume
reorganizing and relocating AFIP. However, other developments could impact
the implementation of those plans. Specifically, Congress is considering
requiring or allowing DOD to establish a new Joint Pathology Center.
^9See U.S. Troop Readiness, Veterans' Care, Katrina Recovery and Iraq
Accountability Appropriations Act, Pub. L. No. 110-28, S 3702, 121 Stat.
112, 144-45 (2007). This law requires DOD to take into account this GAO
report as it develops its detailed plan and timetable for the proposed
reorganization and relocation of AFIP, if the GAO report is available on
or before November 16, 2007. DOD is required to submit its plan no later
than December 31, 2007.
Discontinuing or relocating AFIP services may have minimal impact on DOD,
VA, and civilian communities because alternative services are available
from other sources. Although AFIP is a noted center for pathology
expertise, DOD, VA, and civilian pathologists may obtain pathology
consultations from sources other than AFIP, as other medical institutions
have subspecialty pathology experts that provide this service. Other
institutions also provide pathology education and are used by DOD, VA, and
civilian pathologists to fulfill continuing medical education (CME)
requirements. Further, DOD, VA, and civilian pathologists could continue
to conduct research, using material from the repository, and possibly
through collaborations with other institutions. However, a smooth
transition in services depends on DOD's actions to address challenges
involved in developing new approaches to obtain subspecialty pathology
consultations and manage the repository to facilitate its use for
research. For consultations, these challenges are to determine how to
effectively use existing specialized pathology resources, obtain outside
expertise, and ensure coordination and funding of services to encourage
efficiency while avoiding disincentives to quality care. While DOD has
begun to identify the challenges, it has not developed strategies to
address them. Similarly, whether the repository will continue to be a rich
resource for DOD, VA, and civilian research depends on how DOD populates,
maintains, and provides access to it in the future, but DOD has not
developed its strategies to address issues that will affect the viability
and usefulness of the repository. DOD awarded a contract to study the
usefulness of the material in the repository and will use the study, to be
completed by the end of 2008, to help make decisions on how the repository
will be managed.
We are recommending that DOD include its strategies for organizing
consultation services in its 2007 plan to Congress. Furthermore, we are
recommending that DOD provide information on the status of the
repository's assets and their potential for research within 6 months of
completing its study. We are also recommending that DOD provide a report
to Congress, prior to USUHS assuming responsibility for the repository, on
its implementation strategies for how it will populate, manage, and use
the repository.
In commenting on a draft of this report, DOD generally concurred with the
findings and recommendations. However, our draft report had recommended
that DOD provide information on its implementation strategies for how it
will populate, manage, and use the repository within 6 months of
completing its study. DOD raised concerns with respect to steps it needs
to take before it could report to Congress on its implementation
strategies for how it will populate, manage, and use the repository. As a
result, we altered our recommendations as described above. VA agreed that
GAO's report was factually accurate, but believed it did not sufficiently
describe the impact of closing AFIP. We believe that we provided a
balanced assessment of AFIP's services and the impact of its closing.
Background
In 1862, the Army Surgeon General established a repository in the Army
Medical Museum for disease specimens collected from Civil War soldiers.
The Army Institute of Pathology was created as a part of the museum in
1944, using the museum's extensive collection of disease specimens to
develop expertise in diagnostic pathology. In 1949, the Army Institute of
Pathology was renamed the Armed Forces Institute of Pathology, and the
museum became a unit within AFIP. In 1976, the Department of Defense
Appropriation Authorization Act for Fiscal Year 1977 established AFIP in
its current form, as a joint entity of the Departments of the Army, Navy,
and Air Force, to offer pathologic support to military and civilian
medicine in consultation, education, and research.^10
Role of AFIP
Throughout the early part of the 20th century, AFIP was the only
institution in the country that maintained expertise in every major area
of anatomical pathology, attracting large numbers of consultations,
trainees, and research grants on the basis of the institute's unique
reputation. However, according to AFIP's Scientific Advisory Board, many
changes in modern medical practice over the last several decades have
altered the environment in which AFIP operates. For example, AFIP must now
compete with over one hundred civilian medical institutions, many of which
have in-house experts and comparable subspecialty areas of pathology.
AFIP provides pathology expertise for all branches of the military. AFIP
also provides pathology expertise for VA in exchange for a specified
number of VA staff positions assigned to AFIP. Additionally, AFIP offers
pathology expertise on a reimbursable basis for its civilian customers. To
assist AFIP in this part of its mission, the Department of Defense
Appropriation Authorization Act for Fiscal Year 1977 authorized ARP to be
established as a nonprofit corporation with responsibility for encouraging
and facilitating collaborative work between AFIP and civilian medicine.^11
As such, ARP enters into contracts, collects fees, and accepts research
grants on behalf of AFIP, in support of cooperative enterprises and
interchange between military and civilian pathology.
^10See Pub. L. No. 94-361, S 811, 90 Stat. 923, 933-34 (codified at 10
U.S.C. S 176).
From 1998 through 2006, DOD and others conducted reviews that concluded
that AFIP lacked controls over its financial operations, provided services
for the civilian medical community without adequate reimbursement, and the
costs of the services it provided to VA exceeded the value of the paid
staff positions VA provided in exchange.^12 These reviews concluded that
DOD, in effect, subsidized AFIP's work for VA and civilian customers. In
response to these concerns, AFIP began making changes to its operations in
2000, including the development and implementation of a business plan
meant to increase AFIP's revenue and reduce DOD's level of funding to
AFIP.
DOD Examines AFIP's Future Role
DOD examined AFIP's operations as part of the 2005 BRAC process, which was
intended to find ways to consolidate, realign, or find alternative uses
for current facilities given the U.S. military's limited resources. In
making its 2005 BRAC recommendations, DOD applied statutory selection
criteria that included military value, costs and savings, economic impact
to local communities, community support infrastructure, and environmental
impact.^13 In applying these criteria, the law required that priority
consideration be given to military value, and allowed the other criteria
to be considered to a lesser extent. In DOD's evaluation, AFIP received a
low military value due to its large portion of civilian-related work.
Therefore, DOD recommended disestablishing AFIP by relocating critical
military services and terminating civilian-related activities currently
provided by AFIP.
^11Id. at 90 Stat. 934-36 (codified at 10 U.S.C. S 177).
^12From 1998 to 2002, AFIP was the subject of three program decision
memorandums (documents used by DOD for planning and managerial oversight),
four major DOD reviews, and two DOD Inspector General reviews.
^13See Pub. L. No. 107-107, S 3002, 115 Stat. 1012, 1344-45 (2001)
(codified at 10 U.S.C. S 2687, note). This law authorized the 2005 BRAC
round and revised some of the BRAC procedures. The law also required DOD
to publish its final selection criteria in the Federal Register, which DOD
did in February 2004. See 69 Fed. Reg. 6948-52 (Feb. 12, 2004).
As part of the BRAC process, the Secretary of Defense issued a report
containing his realignment and closure recommendations, which were then
reviewed by the BRAC Commission.^14 The 2005 BRAC Commission's final
report contained recommendations to disestablish AFIP and relocate certain
services that AFIP provides. These recommendations became binding as of
November 9, 2005. In accordance with BRAC statutory authority, DOD must
complete closure and realignment actions by September 15, 2011.^15
AFIP's Key Services Include Consultation, Education, and Research That Benefit
DOD, VA, and Civilian Communities
AFIP pathologists perform diagnostic consultations, education, and
research services benefiting DOD, VA, and civilian communities. In 2006,
AFIP provided over 40,000 consultations, almost half of which were for DOD
physicians. AFIP's educational services include live courses, distance
learning activities, and texts that draw upon pathology material from the
repository with the goal of training physicians in diagnosing the most
difficult-to-diagnose diseases. DOD, VA, and civilian physicians use
AFIP's educational services, but the civilian community uses AFIP's
educational services more extensively than military physicians. Regarding
its research services, AFIP pathologists work individually and in
partnership with other federal and private researchers using material from
the repository to conduct research applicable to military operations as
well as to diagnose and treat diseases affecting military and civilian
health.
Providing Consultations Is AFIP's Primary Mission, and DOD Is Its Most Frequent
Customer
AFIP's primary mission is to provide diagnostic consultations. Its
pathologists spend nearly twice as much time providing this service as
they do providing education and research services. AFIP pathologists
provide consultations for cases referred to them with and without
diagnoses. That is, when physicians--clinicians or general
pathologists--at civilian, DOD, or VA medical centers cannot make a
diagnosis or when they are unsure of their initial diagnosis and are in
need of another opinion, they can send the case to AFIP's subspecialty
pathologists^16 for diagnostic consultation. According to the American
Board of Pathology, there are 10 different areas of subspecialty
pathology, such as dermatopathology and forensic pathology. Additionally,
pathologists are recognized as subspecialists in other areas of pathology
pertaining to particular cancers, such as breast or prostate. Requesting
physicians--those who send cases to AFIP in search of diagnostic
consultations--typically need consultations for more complex cases that
require the additional expertise of a subspecialty pathologist.^17 In the
course of providing these diagnostic consultations to the requesting
physicians, AFIP receives and is able to add pathology material^18 to its
repository. As a result, consultations have been instrumental in expanding
the repository.
^14The BRAC Commission is an independent body that has the authority to
change the Secretary's recommendations if it determines that the Secretary
deviated substantially from the selection criteria. See Pub. L. No.
101-510, S 2903 (codified as amended at 10 U.S.C. S 2687, note). The
commission then makes recommendations to the President for approval or
disapproval. After the President approves the recommendations, he
transmits them to Congress. The recommendations become binding 45
legislative days after presidential transmission or at the adjournment of
Congress, unless Congress enacts a joint resolution disapproving the
recommendations.
^15See Pub. L. No. 101-510, S 2904 (codified as amended at 10 U.S.C. S
2687, note).
Over time, AFIP has increased the amount of services provided for DOD and
decreased the amount of services provided for civilians. The total number
of diagnostic consultations that AFIP provided remained relatively stable
from 2000 to 2004. However, as we previously reported, DOD diagnostic
consultations provided by AFIP increased by 30 percent from 2000 through
2004, while its civilian consultations decreased by 28 percent.^19 We also
reported that nearly all of the decrease in civilian consultations
occurred in the 2 years after AFIP announced that it would raise its
consultation fees beginning in January 2003. According to AFIP and
civilian pathologists, this decrease in civilian diagnostic consultations
was also attributed to a more competitive marketplace for obtaining
consultations. Additionally, these pathologists also cited the loss of
nationally recognized experts at AFIP as another possible reason for the
decline in the number of civilian diagnostic consultations being sent to
AFIP.
^16Unlike general pathologists, subspecialty pathologists specialize in a
particular organ system and gain additional exposure, experience, and
expertise in diseases and conditions affecting the tissues of that system
than general pathologists.
^17When AFIP receives a case for consultation, staff assign the case to
the appropriate subspecialty department based on the requesting
physician's indications. AFIP's structure allows pathologists to consult
with their colleagues who have expertise in different subspecialties as
needed.
^18Pathology material includes paraffin blocks that enclose preserved
tissue, gross tissue samples, microscopic glass slides, and clinical
records such as X-rays and photographs.
^19 [37]GAO-05-615 , 22-27.
In 2006, AFIP provided almost half of its consultations to DOD physicians.
From 2005 to 2006, AFIP decreased the total number of consultations it
provided from 44,169 to 41,582. Consistent with earlier trends from 2000
to 2004, AFIP continued to increase the number and percentage of
consultations provided to DOD and decrease the amount provided to the
civilian community from 2005 to 2006. (See table 1.) In 2006, the largest
percentage of consultations, approximately 48 percent, was conducted for
DOD, followed by those for VA and civilian physicians at nearly 27 percent
and 25 percent, respectively. AFIP also provided about 1 percent of its
consultations for others, which included other federal agencies and
foreign military services. While AFIP receives consultation requests from
all over the world, consultations are heavily concentrated from more
populous states and the East Coast. (See app. II for maps of AFIP's 2006
consultations.)
Table 1: Number and Percentage of AFIP Consultations for Customers, 2005
and 2006
2005 2006
Percentage of Percentage of
Customer type Consultations total Consultations total^a
DOD^b 19,464 44.1 19,856 47.8
VA 11,520 26.1 11,083 26.7
Civilian 12,708 28.8 10,287 24.7
Other federal 456 1.0 334 0.8
agencies^c
Foreign^d 21 0.0 22 0.1
Total 44,169 100.0 41,582 100.0
Source: GAO analysis of DOD data.
aDoes not add to 100 due to rounding.
bIncludes the Army, Navy, and Air Force.
cIncludes the Department of Health and Human Services, Department of
Homeland Security, and others.
dIncludes consultation requests from physicians from other countries, such
as countries in Europe, Africa, or Asia.
In 2006, about 62 percent (25,621) of AFIP's cases were for consultations
where AFIP pathologists reviewed the initial diagnoses from DOD, VA,
civilian, or other physicians for confirmation or change. For these cases,
AFIP pathologists changed the initial diagnoses from requesting physicians
in 10,987 cases, or about 43 percent of the time. For the remaining 57
percent of the cases (14,634), AFIP confirmed the requesting physicians'
initial diagnoses.^20 When AFIP's diagnoses differ from the requesting
physicians' initial diagnoses, it classifies the changes as either minor
or major. According to AFIP, a minor change often involves a change in
severity of the condition diagnosed or the choice of appropriate therapy.
For example, the initial diagnosis may have correctly identified a tumor
as malignant but may have assigned an incorrect type or level of
aggressiveness, which could affect treatment and prognosis. In addition,
AFIP classifies a change as major if it involves a change in the nature of
the condition diagnosed. For example, a major change would include
changing a diagnosis from malignant to benign. Both minor and major
diagnosis changes can lead to a different treatment and, ultimately, a
different outcome for the patient. As shown in table 2, most of AFIP's
changes to initial diagnoses that were provided by requesting physicians
were classified by AFIP as minor changes.
Table 2: Consultation Outcomes Where an Initial Diagnosis Was Provided,
for 2006
Outcome Consultations Percentage of total^a
Initial diagnosis confirmed 14,634 57.1
Minor change^b 10,116 39.4
Major change^b 871 3.4
Total 25,621 100.0
Source: GAO analysis of DOD data.
aDoes not add to 100 due to rounding.
bMinor and major changes were classified as such by AFIP.
The type of consultations DOD, VA, and civilian physicians seek from AFIP
differ somewhat, both in terms of the number of cases sent without a
diagnoses and the type of pathology expertise requested. For example, 47
percent of DOD's consultation requests were sent without an initial
diagnosis, compared to 27 percent from VA and 31 percent from civilian
physicians. This may be due, in part, to the type of expertise DOD and
civilian physicians most commonly need, which also differs. For example,
in 2006, almost a quarter of all DOD consultations were in the area of
forensic toxicology, which includes examining material from autopsies and
testing biological specimens for alcohol and drugs. However, VA physicians
most frequently requested AFIP's environmental toxicology diagnostic
consultations, while civilian physicians most frequently requested hepatic
consultations--involving diseases of the liver--as well as
gastrointestinal consultations. The other consultation service most
frequently requested by DOD, VA, and civilian pathologists was for
dermatopathology--or the interpretation of skin biopsies.
^20According to AFIP pathologists, confirmation of an initial diagnosis is
important because physicians seeking a consultation generally do not begin
treating a patient until another pathologist confirms that the initial
diagnosis is correct.
AFIP Provides Varied Educational Services, Used Primarily by Civilian Physicians
AFIP, in conjunction with ARP, offers a variety of courses, conferences,
and other educational services, generally for physicians, and tailors its
curriculum to the most common as well as the most difficult-to-diagnose
diseases. AFIP staff design and conduct live and distance learning courses
that aid physicians in expanding their medical knowledge as well as
fulfilling their state licensure requirements for CME credit. AFIP's
educational services cover a range of topics in the fields of pathology,
radiology, and veterinary pathology, with particular emphasis on
identifying emerging diseases, offering new insights into known diseases,
and giving hands-on experience in diagnosing difficult cases. In
developing material for conferences, courses, and texts, AFIP staff query
a database of recent consultations searching for the most common missed
diagnoses--that is, those cases in which the requesting physician
misdiagnosed the case, as well as diagnoses in which the requesting
physician most frequently did not make an initial diagnosis.
In 2006, AFIP, in conjunction with ARP, offered 28 formal courses, 24
video teleconferences, and 4 Web-based courses. These courses qualify for
CME credit, which assists DOD, VA, and civilian pathologists and other
physicians in fulfilling state requirements for maintaining their medical
licenses.^21 Civilian physicians use AFIP's training services more
extensively than DOD and VA physicians. In 2006, 61 percent of the
students attending AFIP's CME courses were civilians, 34 percent were DOD
attendees,^22 and 5 percent were from VA. Most live CME courses are
attended predominantly by civilians. For example, in 2006, 96 percent of
the residents who attended the Radiologic-Pathologic Correlation course
were civilians. However, some courses are solely attended by military
health professionals because they involve issues specific to DOD or
because AFIP does not allow civilians to attend classes such as its Air
Force Medical Forensic Sustainment course. Overall, AFIP's courses have
attracted instructors and students from around the world. In 2006,
individuals representing over 70 institutions, including the Federal
Bureau of Investigation, the National Institutes of Health, private
academic institutions and medical centers, and MTFs participated in AFIP's
CME program.
^21In 2006, AFIP offered six courses, including the Radiologic-Pathologic
Correlation course, targeted to medical residents. Practicing physicians
are permitted to attend any of AFIP's courses for residents and may earn
CME credit for attendance.
^22DOD attendees include both active duty military personnel and
physicians employed by DOD as federal government employees.
According to military pathologists, AFIP's distance learning programs are
a convenient and economical way to obtain CME requirements and fulfill
state licensure requirements. AFIP's distance learning programs include
AskAFIP, an online database maintained and operated by AFIP. To hone
diagnostic skills, AskAFIP allows users to query a database that contains
information from AFIP's collection of specific diagnoses, texts, case
materials, and images from the repository. DOD, VA, and civilian
physicians have access to AskAFIP. Also, as part of its distance learning
educational services, AFIP's pathologists review diagnoses provided by VA
pathologists--known as the Systematic External Review of Surgicals
program.^23
In addition to offering courses, in conjunction with ARP, AFIP publishes
examples of clinical-pathologic correlations, which describe the
relationships that exist between the clinical symptoms or attributes
exhibited by a patient and the pathological abnormalities of a specific
disease or type of tumor. These correlations are published in texts called
fascicles,^24 which DOD, VA, and civilian pathologists told us are a
primary reference source and serve as an important, frequently used tool
as they practice pathology.^25 The fascicles are updated to capture the
more recent developments in pathology.
^23Unlike the consultation process, the Systematic External Review of
Surgicals program is a peer review or quality assurance process. VA policy
requires its pathologists to submit cases--in which the VA pathologist
already rendered a diagnosis--to AFIP. Then, AFIP subspecialty
pathologists review the rendered diagnosis for quality review purposes and
provide feedback to the pathologist who submitted the case in an effort to
improve the practice of pathology.
^24ARP holds the copyright for these fascicles.
AFIP's Research Benefits DOD, VA, and Civilians
The combination of unique case material and expertise of AFIP pathologists
facilitates AFIP's research that benefits DOD, VA, and civilian medicine
and results in hundreds of publications each year. Research is conducted
by AFIP pathologists, as well as by other federal and private researchers
in collaboration with AFIP pathologists, primarily using material from the
repository.^26 All outside researchers are required to collaborate with an
AFIP pathologist in order to access AFIP's materials.
The repository contains over 3 million disease specimens and their
accompanying case histories dating back over 150 years. Because of the
large volume of cases in the repository, researchers can conduct studies
of considerable sample size. Since AFIP receives pathology material for
many difficult-to-diagnose diseases, the repository contains complex and
uncommon cases that have accumulated over time. Studying these samples
allows for advances in diagnosis and treatment of diseases. For example,
AFIP has accumulated a large collection of gastrointestinal stromal
tumors, a relatively uncommon tumor. Recent studies involving this
collection have led to advances in the identification of, and therapy for,
this tumor. One of the responsibilities of AFIP pathologists is to
classify the material that AFIP receives into the repository so that
researchers can access it in the future. As medical knowledge evolves,
AFIP pathologists reclassify material in the repository to better
characterize it for future use. AFIP staff are also in the process of
putting material from the repository in digital form to expand its use for
research.
AFIP conducts and collaborates on research applicable to military
operations and general medicine, so its research affects DOD, VA, and
civilian communities. Although "militarily relevant" research has not been
well-defined, AFIP staff said it generally includes subjects of direct
interest to the military. For example, according to AFIP staff, research
conducted in collaboration with the Armed Forces Medical Examiner has led
to developments such as improved body armor and acute care of wounded
personnel. Further, AFIP conducts and collaborates on infectious disease
and cancer research, which has applicability for the civilian community as
well. AFIP's infectious disease research has focused on the
characterization of potentially epidemic organisms, such as severe acute
respiratory syndrome, as well as on the development of improved vaccines
and the detection of biologic toxins, such as those that may be used in
biological warfare. AFIP's cancer research, including breast, gynecologic,
and prostate cancers, has resulted in more accurate diagnosis and
development of better treatment methods. Table 3 provides examples of
AFIP's research projects, including their impact.
^25There are different types of fascicles, for example Tumors of the
Kidney, Bladder, and Related Urinary Structures and Non-Neoplastic
Disorders of the Lower Respiratory Tract.
^26AFIP also maintains, in conjunction with ARP, over 30 international
registries, such as Depleted Uranium, Agent Orange, and tumor registries.
A comprehensive database of disease diagnoses and patient demographic
data, incorporating all cases ever reviewed at AFIP, is available to
researchers.
Table 3: Examples of AFIP's Research Projects
Research project Description
Body armor AFIP conducted a study examining full autopsies on U.S.
troops killed in Iraq and Afghanistan from March 2003 to
mid-2005. Investigators found that 80 percent of the
fatalities could have been prevented by better
protection for the shoulder, back, chest, and side
areas. As a result, DOD decided to redesign body armor.
Thoracic needle AFIP conducted a study examining why field medics'
procedures to treat collapsed lungs were not working.
Researchers discovered that a soldier's muscle thickness
is greater than the average person's muscle thickness.
As a result, DOD now uses thicker, longer needles to
penetrate the lung.
Spanish influenza The 1918 influenza pandemic killed more than 50 million
people worldwide. AFIP pathologists were able to decode
the genetic sequence of the 1918 strain by examining
tissue samples in the repository from World War I
soldiers who had died of the disease in 1918.
Understanding the genetic sequence of this influenza
virus could aid in predicting future influenza pandemics
and in developing interventions and treatment of
virulent influenza viruses.
Reye syndrome Reye syndrome primarily affects children, causing sudden
brain damage and liver function problems. AFIP
pathologists found that Reye Syndrome was associated
with the use of aspirin to treat chickenpox or upper
respiratory infection in children. As a result of
understanding this association, the Food and Drug
Administration issued a package insert for aspirin
warning against prescribing aspirin to infants and
children with chickenpox or flu. There has been a sharp
decline in the number of infants and children with Reye
Syndrome since this discovery, and it is now very rare.
Source: GAO analysis of DOD data.
The research conducted at AFIP results in hundreds of publications per
year, but it has been declining. For example, in 2005 researchers at AFIP
published 174 peer-reviewed articles and 121 abstracts, and in 2006
researchers at AFIP published 145 peer-reviewed articles and 73 abstracts.
In a previous GAO report, we found that from 2000 through 2004, the number
of research protocols at AFIP declined from 371 to 296.^27 AFIP staff said
that they began to focus on increasing militarily relevant research and
reducing DOD-funded civilian-focus research as early as 2001.
^27See [38]GAO-05-615 . A research protocol is a detailed proposal,
approved by AFIP's research committee, which describes the research that
will be completed.
DOD Has Specific Plans to Terminate Most Services Currently Provided by AFIP and
Is Developing Plans to Relocate the Others
The 2005 BRAC provision specifies that AFIP be disestablished.
Accordingly, most services currently provided by AFIP will be terminated
and other services will be relocated or outsourced. Specifically:
o DOD plans to outsource second-opinion consultations and some
initial diagnostic consultations to the private sector through a
newly established PMO.
o With the exception of two educational courses, DOD does not plan
to retain and relocate the educational programs currently offered
by AFIP.
o DOD plans to halt AFIP's research and realign the repository,
which is AFIP's primary research resource, to the Forest Glen
Annex, Maryland, under the management of USUHS.
The BRAC provision allows DOD the flexibility to retain
capabilities that were not specifically addressed in the
provision. In accordance with this statutory authority, the
ASD(HA) has retained four additional AFIP services and is
considering whether to retain six others. According to DOD's most
recently developed implementation plan, dated February 2007, DOD
had planned to begin implementation of the BRAC provision relating
to AFIP in July 2007 and to complete action by September 2011.
However, a provision from the 2007 supplemental appropriations act
prevents DOD from reorganizing or relocating any AFIP functions
until after DOD has submitted detailed plans and timetables for
the proposed reorganization and relocation to Congress.^28 Once
the reorganization plan has been submitted, DOD can resume
reorganizing and relocating AFIP.
Most of AFIP's Services Will Be Terminated, but Some Will Be Relocated
DOD plans to terminate AFIP's provision of diagnostic
consultations and outsource certain DOD diagnostic consultations
to the private sector through a newly established PMO. More
specifically, the BRAC provision requires that the PMO be
established at the new Walter Reed National Military Medical
Center in Bethesda, Maryland,^29 to coordinate pathology results,
contract administration, quality assurance, and control of DOD
second-opinion consults worldwide. DOD plans to relocate
sufficient personnel from AFIP to the new PMO to conduct its
activities.^30 Further, DOD's justification for this provision
states that DOD will also rely on the civilian market for
providing initial diagnoses when the local pathology labs'
capabilities are exceeded.
^28Section 3702 of the appropriations act requires DOD to take into
account this GAO report as it develops its detailed plan and timetable for
the proposed reorganization and relocation of AFIP, if this GAO report is
available on or before November 16, 2007. This effectively suspends the
disestablishment and relocation of AFIP services until DOD submits its
plan to Congress; the deadline for submission is December 31, 2007.
In determining the legal implications of the BRAC provision with
respect to consultation services, DOD's Office of General Counsel
concluded that military second-opinion consultations as currently
provided by AFIP would not be subject for retention because the
PMO would be required to outsource these consultations. Initial
diagnoses would either be provided by military pathologists or
possibly military subspecialty pathologists at MTFs when possible
or outsourced through the PMO. Although the PMO would not
coordinate civilian diagnostic consultations, DOD has not
determined whether it would allow VA or other federal agencies to
obtain diagnostic consultations--either initial or
second-opinion--through the PMO. The PMO working group, including
DOD and VA officials, met in August 2007 to discuss the
establishment of the PMO.
Regarding the retention of educational services, DOD does not plan
to relocate any educational services currently offered by AFIP
with the exception of the enlisted histology technician training
and the DOD Veterinary Pathology Residency Program. The BRAC
provision requires DOD to relocate the enlisted histology
technician training to Fort Sam Houston, Texas. The DOD Veterinary
Pathology Residency Program would be relocated to Forest Glen
Annex, Maryland.
With respect to the research, DOD plans to realign the repository,
which is AFIP's primary research resource, to Forest Glen Annex,
Maryland, to be managed by USUHS. USUHS issued a Request for
Proposal in May 2007, for the purpose of contracting for a review
of the quality of the pathology material and associated case
records contained in the repository. USUHS officials told us that
they will make further decisions regarding laboratory and storage
facility requirements for the repository, as well as plans for
staffing and research uses, when the evaluation is complete.
Pending the outcome of this review, USUHS may employ 10-12
pathologists who would spend the majority of their time on
research; these pathologists would also be responsible for
classifying pathology material in the repository.
^29The BRAC Commission recommended that DOD realign Walter Reed Army
Medical Center, Washington, D.C., as follows: relocate all tertiary
(subspecialty and complex care) medical services to National Naval Medical
Center, Bethesda, Maryland, establishing it as the new Walter Reed
National Military Medical Center, Bethesda, Maryland.
^30Emphasis would be placed on preserving AFIP consultation services to
military and other federal customers until the PMO is operational, with
earlier disestablishment of AFIP research and education activities.
Aside from the AFIP services discussed above, the BRAC provision
required that some of AFIP's other services be retained by DOD and
relocated into other facilities. For example, the provision
requires relocating Legal Medicine to the Walter Reed National
Military Medical Center in Bethesda, Maryland, and the relocation
of the Armed Forces Medical Examiner, DNA (deoxyribonucleic acid)
Registry, and Accident Investigation to Dover Air Force Base,
Delaware.
As part of its review regarding the disestablishment of AFIP, the
BRAC Commission found that the medical professional community
regarded AFIP and its services as integral to the military and
civilian medical and research community. The commission also found
that DOD substantially deviated from its selection criteria by
failing to sufficiently address several AFIP functions. As a
result, the commission amended DOD's initial recommendation to add
that AFIP capabilities not specified in the final recommendation
would be absorbed into other DOD, federal, or civilian facilities,
as necessary. The revised language was approved by the President
as part of the final BRAC provision. As revised, DOD has the
flexibility to review AFIP capabilities or services not
specifically addressed in the BRAC provision to determine which
functions to retain.
As a result of the amendment, the ASD(HA) informed key DOD
officials^31 in a November 16, 2006, memorandum that he had
approved the retention of four services--the DOD Veterinary
Pathology Residency Program, Automated Central Tumor Registry,
Center for Clinical Laboratory Medicine, and Patient Safety
Center. He also informed them that the remaining AFIP services
would be disestablished unless any of the key officials identified
the need to retain specific services. Based on responses from the
key officials, an additional six AFIP services were recommended
for retention. As of September 2007, the ASD(HA) had not made a
final decision on them. These six services include diagnostic
telepathology, two biodefense projects, reserve biological select
agent inventory, depleted uranium (DU) testing, and cystic
fibrosis testing. In addition, VA expressed an interest in having
DOD retain the DU testing capability. Table 4 summarizes AFIP
services that will be relocated or established as specified in the
BRAC provision, those that were subsequently added by the ASD(HA)
to be retained, and those that were recommended for retention by
the DOD officials and are awaiting final decision. (See app. III
for a description of services currently performed by AFIP that are
to be retained and relocated, or newly established, or are
awaiting final decisions.)
^31These key DOD officials include the Surgeon General of the Army,
Surgeon General of the Navy, Surgeon General of the Air Force, President
of USUHS, and Deputy Director of TRICARE Management Activity.
Table 4: Services Currently Performed by AFIP That Are to Be Retained and
Relocated, or Established, or Are Awaiting Final Decisions
Service Proposed locations^a
Services required to be retained by
the BRAC provision
Legal Medicine Walter Reed National Military Medical
Center, Md.
National Museum of Health and Walter Reed National Military Medical
Medicine Center, Md., managed by Uniformed
Services University of the Health
Sciences (USUHS), Md.
Repository Forest Glen Annex, Md., managed by
Uniformed Services University of the
Health Sciences (USUHS), Md.
Armed Forces Medical Examiner, DNA Dover Air Force Base, Del.
Registry, and Accident
Investigation
Enlisted histology technician Fort Sam Houston, Tex.
training
Service to be established as specified by BRAC provision
Program Management Office (PMO) Walter Reed National Military Medical
Center, Md.
Services designated for retention
by ASD(HA)
DOD Veterinary Pathology Residency Forest Glen Annex, Md.
Program
Automated Central Tumor Registry Forest Glen Annex, Md. managed by
Uniformed Services of the Health
Sciences (USUHS), Md.
Center for Clinical Laboratory Walter Reed National Military Medical
Medicine Center, Md.
Patient Safety Center Walter Reed National Military Medical
Center, Md.
Services being considered for retention by key DOD officials and awaiting
a final decision
Diagnostic telepathology Walter Reed National Military Medical
Center, Md., or Fort Belvoir, Va.^b
Biodefense Project - Joint Fort Detrick, Md.
Biological Agent Identification and
Diagnostic System
Biodefense Project - Critical Aberdeen Proving Ground, Md.^b
Reagent Program
Reserve Biological Select Agent Aberdeen Proving Ground, Md.^b
Inventory
Depleted uranium testing Aberdeen Proving Ground, Md.^b
Cystic fibrosis testing Outsourced
Source: GAO analysis of DOD data.
aThe new locations of Legal Medicine; the Armed Forces Medical Examiner,
DNA Registry, and Accident Investigation; and enlisted histology
technician training were specified in the BRAC provision.
bAs of September 2007, DOD had not finalized decisions regarding the
locations of these services.
Planned Implementation to be Completed by 2011
According to DOD's most recently developed implementation plan,^32
execution of the BRAC provision regarding AFIP was scheduled to begin in
July 2007 and be complete by September 2011. Figure 1 summarizes DOD's
plans to terminate AFIP's three key services by December 2010. It also
illustrates DOD's timeline that would have relocated other AFIP services
that were designated to be retained by the BRAC provision. Several rounds
of staff reductions were anticipated to occur as DOD terminated or
relocated AFIP services. As figure 1 shows, DOD's plans left a lag time
between when AFIP DOD diagnostic consultations ended in December 2010 and
when the PMO was expected to be operational in September 2011.
^32DOD's most recent BRAC implementation plan pertaining to AFIP was
developed in February 2007.
Figure 1: DOD's Proposed Timeline for BRAC Implementation Pertaining to
AFIP
Implementation of these plans were put on hold by the requirements of
section 3702 of the fiscal year 2007 supplemental appropriations act,
which suspended all BRAC actions affecting AFIP until after DOD submits
detailed plans to the House and Senate Appropriations and Armed Services
Committees, which are due by December 31, 2007. DOD officials acknowledge
that the timeline as envisioned in their February 2007 implementation plan
can no longer be met and the full amount of onetime savings from
disestablishment of AFIP will not be realized, although they believe that
they may still be able to complete all actions required by the BRAC
provision by 2011.
While DOD is required to share more information regarding its plans with
Congress before the end of the year, other developments could impact the
implementation of those plans. Specifically, on May 17, 2007, the House
passed H.R. 1585, a bill for the National Defense Authorization Act for
Fiscal Year 2008, which contains a provision that would require DOD to
establish a "Joint Pathology Center" at the National Naval Medical Center
in Bethesda. On October 1, 2007, the Senate passed its version of the same
bill. However, the Senate-passed version contains a provision that would
authorize, rather than require, DOD to establish a Joint Pathology Center
at Bethesda, "to the extent consistent with the final recommendations of
the 2005 [BRAC] Commission as approved by the President." If a new Center
is established under either provision, it would be required to provide
diagnostic pathology consultation, pathology education, and diagnostic
pathology research. In addition, the Senate bill would require that the
Center, if established, provide maintenance and continued modernization of
the tissue repository. As of the publication of this report, the House and
Senate had not reached agreement at conference on any provision related to
a new Joint Pathology Center.
Closing AFIP May Have Minimal Effect, but Management Strategy Is Important to
Address Key Challenges
Although AFIP is a noted center for pathology expertise, closing AFIP may
have minimal effect on DOD, VA, and civilian communities because pathology
services are available to them elsewhere. However, a smooth transition
depends on DOD's actions to address key challenges involved in developing
new approaches to obtaining subspecialty pathology consultations and
managing the repository to facilitate its use for research. DOD and VA
officials have begun to identify the challenges, but have not decided upon
strategies to address them.
DOD, VA, and Civilian Physicians May Be Able to Obtain Key Services from Other
Institutions
In large part, DOD, VA, and civilian pathologists may be able to obtain
services elsewhere to replace those currently provided by AFIP.
Diagnostic consultations: Other medical institutions currently provide
diagnostic consultations that require subspecialty expertise. For example,
Massachusetts General Hospital (Boston, Massachusetts) and M. D. Anderson
Cancer Center (Houston, Texas) each provide about 60,000 or more pathology
consultations per year. While AFIP has many different subspecialty areas,
major civilian medical institutions, such as The Johns Hopkins Hospital
(Baltimore, Maryland) and Memorial Sloan-Kettering Cancer Center (New
York, New York) have from 10 to 17 different subspecialty areas,
respectively.^33 Pathologists we interviewed emphasized the importance of
being able to obtain consultations from expert pathologists, wherever they
may work. They also stated that pathologists with particular expertise who
move from AFIP to the private sector may be able to continue to provide
consultations from whichever institutions they may join. Most DOD and VA
pathologists noted that even though MTFs and VA medical centers can
readily access AFIP consultations without incurring additional fees, they
already use subspecialty pathologists from civilian medical institutions
on occasion for consultations due to their needs for particular
subspecialty expertise and concerns about obtaining a diagnosis in a
timely manner. In addition, some MTFs have subspecialty pathologists who
can provide consultations for other military physicians. For example,
Brooke Army Medical Center and Wilford Hall Medical Center--both located
in San Antonio, Texas--each have over seven different subspecialty areas.
According to pathologists from the five MTFs we interviewed, subspecialty
pathologists from their centers currently provide consultations to other
nearby MTFs.
Pathology education: Other institutions also provide pathology education.
For example, CAP offers educational courses covering a range of topics
such as histotechnology and molecular pathology. DOD, VA, and civilian
pathologists that we interviewed told us that they have fulfilled CME
requirements through other institutions and could continue to do so.
Pathologists we interviewed said that DOD and VA pathologists generally
make independent decisions about which classes to attend and how to meet
accreditation requirements. Military pathologists we interviewed also said
that due to limited budgets, pathologists generally do not travel to AFIP
to attend courses because other pathology organizations, such as CAP,
offer CMEs that are accessible without the need to travel. Most DOD, VA,
and civilian pathologists we interviewed said that AFIP's
Radiologic-Pathologic Correlation course is unique and valuable to the
radiology profession. Some of the pathologists we interviewed said that
this is because the course utilizes the expertise of physicians who work
with pathology material from a large volume of difficult-to-diagnose
cases, requires attendees to bring unique specimens for class analysis and
discussion, and utilizes material from AFIP's repository, which houses a
comprehensive collection of specimens. Further, many pathologists and
representatives from radiology organizations told us that it is the most
common way radiology residents fulfill a requirement to have specific
training in pathology. Although the course is recognized as being unique,
according to guidance set forth by the Accreditation Council for Graduate
Medical Education, radiologists could fulfill their accreditation
requirements through avenues other than AFIP. In addition, according to
DOD officials, it is not DOD's mission to train civilian radiology
residents, although we believe that DOD could be in a position to assist
outside groups if any expressed interest in becoming responsible for
maintaining the course.
^33The American Board of Pathology recognizes 10 different areas of
subspecialty pathology such as cytopathology, dermatopathology, and
forensic pathology. Other areas of specialty expertise are recognized by
military and civilian pathologists from major medical centers we
interviewed such as genitourinary, gynecology, and breast pathology. Thus,
military and civilian medical centers determine the number of
subspecialties they have in accordance with the different subspecialties
recognized by the American Board of Pathology as well as those that focus
on particular cancers.
Research services: The type of research historically conducted by AFIP
could be conducted at other institutions or by pathologists who remain
with DOD. USUHS will continue to perform militarily relevant, biomedical
research, focusing on health promotion and disease prevention, as it gains
responsibility for the repository--AFIP's primary research tool.
Additionally, the Office of the Armed Forces Medical Examiner has also
been responsible for conducting research applicable to military
operations. Because it is being retained, it could continue to do so.
Also, AFIP has partnered with other government, academic, and private
sector institutions to carry out research services. Specifically, AFIP
staff have conducted research affecting general medicine through
collaborations with external organizations, such as The Johns Hopkins
Hospital and the Mayo Clinic. These organizations will likely continue to
fund medical research and could possibly continue to conduct research
using pathology material from the repository. Although USUHS has not
finalized its plans regarding the repository, its intent is to make the
pathology material accessible to others including civilian researchers, to
the extent it is approved by DOD, practicable, and legally feasible.
DOD Faces Challenges in Ensuring That Military Physicians' Access to
Subspecialty Consultation Services Is Maintained at a Reasonable Cost
Given that AFIP is a central source that provides its customers with
definitive consults on the most difficult-to-diagnose cases, DOD and VA
pathologists face challenges in obtaining similar consultative expertise
once AFIP is disestablished. These challenges include determining how to
effectively use existing subspecialty pathology resources, obtain outside
expertise, and ensure coordination and funding of services to encourage
efficiency while avoiding disincentives to quality care. In addition, DOD
must decide whether VA could obtain consultation services through the PMO
and whether VA will be able to provide some subspecialty pathology
expertise for DOD. While DOD and VA officials have begun the process to
identify these challenges, as of mid-August 2007, they had not yet
developed management strategies to mitigate them.
Effective utilization of existing resources: While DOD officials told us
that they might be able to perform some in-house diagnostic consultations
for MTFs, they have not evaluated their existing medical resources to
determine the extent to which such consultation services can be performed.
According to DOD officials, some large MTFs have subspecialty expertise
and might be able to absorb some of the demand for consultations, but DOD
has not identified the potential volume and type of consultations that
these large MTFs could absorb. Further, DOD pathologists expressed
concerns that MTFs would not be able to absorb many additional
consultations without increasing the number of subspecialty pathologists
staffed at MTFs. This could be challenging, they said, because it is
difficult to retain pathologists within the military. Because DOD is
retaining some of its pathology capabilities from AFIP under the BRAC
provision, such as the Armed Forces Medical Examiner, it will continue to
have expertise available to provide services in the area of forensic
toxicology--DOD's most frequently used consultation service in 2006.
Further, several DOD officials were concerned that the DOD General
Counsel's interpretation of the BRAC provision requiring outsourcing
through the PMO would preclude DOD from providing second-opinion
consultations from expertise within its MTFs. In addition, although VA may
be able to absorb some of its own consultations using its subspecialty
pathologists, including those who are currently assigned to AFIP, VA
pathologists told us that VA is limited in how many additional
consultations its current subspecialty pathologists could provide.
The PMO process: How the PMO functions and obtains diagnostic services
from medical centers outside DOD and VA has important implications, both
from a quality of care and a cost standpoint. DOD and VA officials we
interviewed indicated that DOD faces challenges in developing the new PMO
that can outsource for quality pathology services; such challenges involve
issues related to the timeliness of consultations and the ability to
obtain appropriate expertise at a reasonable cost. As of August 2007, DOD
has not formulated its management strategies for addressing the following
issues concerning how the PMO will function.
o Assisting other federal agencies with obtaining consultations.
Although DOD has discussed the possibility that the PMO could
include VA in outsourced diagnostic consultations, no decisions
had been made as of mid-August 2007. Since VA has received over a
quarter of AFIP's total consultations, VA officials have expressed
an interest in continuing to receive consultations through the PMO
once DOD discontinues offering AFIP consultations. VA officials
also expressed concerns about the cost of obtaining consultations
outside of AFIP, which they estimated to be much greater than the
financial support it currently provides to AFIP for its services.
In addition, the officials stated that AFIP has been responsible
for VA's DU program,^34 and as of June 2007, VA officials were
uncertain about the extent to which staff and equipment providing
these services would be sufficient to meet the future needs. VA
officials stated that their agency did not have the equipment or
expertise to conduct the analyses needed for this program, and for
testing of other types of embedded fragments, such as cobalt,
nickel, and tungsten. VA officials indicated that testing for DU
and other potentially harmful embedded fragments plays an
important role in providing high quality health care to recently
injured combat veterans. As we previously discussed in this
report, DOD officials are considering the possibility of retaining
DU testing.
o Obtaining consultation services. Several military pathologists
expressed concerns about the challenges DOD and VA would face in
identifying and obtaining needed subspecialty expertise from
pathologists. These concerns stem, in part, from their
understanding of AFIP's capabilities to provide consultations for
difficult-to-diagnose cases by involving different types of
subspecialty pathologists as needed. Within AFIP,
cross-consultation among experts is available under one roof. As
DOD will have to determine a new method for obtaining
consultations using the PMO, military pathologists expressed
concerns that it might be more difficult to access expertise
dispersed among different institutions to obtain accurate
diagnostic information. DOD and VA pathologists also expressed
concerns regarding whether continuity of patient care would be
maintained for retired military personnel if pathology specimens
from active duty personnel and veterans are no longer sent to one
central laboratory, such as AFIP. At present, if a patient has had
a previous consultation, the material is available from the
repository for comparison if AFIP is requested to conduct another
consultation at a later date for the same patient. This can be
important for the patient's care--for example, in determining if a
patient's cancer is metastasizing or if a precancerous condition
is worsening. AFIP pathologists expressed concern that patient
care could be compromised if the pathologists providing
consultations could no longer obtain their patients' previous
specimens, slides, or case notes from the repository. In addition,
according to an AFIP pathologist, the repository is particularly
valuable for AFIP's consultation services because it can serve as
a reference tool to compare pathology material from one patient to
that of many others to confirm a diagnosis. VA and AFIP
pathologists have raised concerns about whether alternate sources
of consultation services obtained through the PMO will be able to
provide the same continuity or quality of service unless
pathologists from these alternate sources can use the repository
as a reference. Further, DOD pathologists expressed concern about
whether private sector institutions with the best subspecialty
pathology expertise can absorb the 40,000 consultations that have
been conducted by AFIP annually. DOD pathologists also indicated
that as of August 2007, DOD had not yet developed a management
strategy to address this challenge.
^34The VA DU program is responsible for providing clinical surveillance to
veterans and active duty personnel who have the highest risk of DU
exposure (primarily those with retained DU fragments). Currently, the DU
program relies on AFIP to perform analyses of specimens from veterans and
active duty personnel potentially exposed to DU. The AFIP laboratory is
one of the few facilities nationwide that are able to measure very low
concentrations of uranium in urine, blood, and semen specimens with a high
degree of accuracy and to discriminate between natural uranium and
depleted uranium based on isotopic analysis.
o Timeliness of consultation services. DOD pathologists we
interviewed are also concerned that obtaining consultations may
take longer than it does under AFIP because it is unclear how DOD
will identify and obtain needed pathology expertise. Timeliness of
consultation services is important. For example, understanding the
aggressiveness and particular stage of a cancer in a given point
in time can influence patient treatments and outcomes. Some
pathologists also anticipate that turnaround time for DOD's
consultations may increase due to difficulty coordinating among
pathologists with varied subspecialty expertise that are dispersed
among different institutions and that this could impair the
quality of services that DOD obtains. As of August 2007, DOD had
not outlined the management strategy that it will pursue to ensure
timely access to consultative services.
o Funding mechanisms. DOD pathologists' access to subspecialty
pathology expertise can also be impacted depending on how DOD
plans to mitigate funding incentives related to centralization or
decentralization of the budget. According to DOD officials, as of
July 2007, DOD had not made decisions regarding whether the budget
for consultations would be maintained centrally at the PMO or if
each MTF would receive a separate budget for outsourced
consultations. Because DOD pathologists did not have to pay for
AFIP's consultation services, there was no financial disincentive
to use them. Several pathologists we interviewed expressed concern
that decentralized funding for consultation services would create
disincentives to obtaining consultations and could ultimately
affect the quality of the medical care the military would receive
for such services. More specifically, these officials asserted
that a decentralized funding system would require a Department of
Pathology Chair within an MTF to scrutinize the department's
competing demands for resources and make decisions about whether
to obtain outside pathology expertise or spend financial resources
on other patient care needs. VA pathologists also expressed
concern that funding issues could contribute to increasing the
difficulty of obtaining subspecialty consultations. If
pathologists cannot obtain subspecialty consultations when they
are unsure of their diagnosis, patients might be misdiagnosed.
This is particularly relevant since, as we discussed earlier in
this report, AFIP has changed requesting physicians' initial
diagnoses for about 43 percent of the cases it reviews.
o Minimizing costs of services through volume discounts. By
working with VA, DOD could further increase its economies of scale
by purchasing a higher volume of consultation services. However,
several DOD and VA pathologists expressed concerns that if DOD
chooses to obtain services from the lowest bidder, the quality of
consultations could be compromised. They informed us that large
national laboratories would likely be the lowest bidders, but
these institutions might lack the subspecialty expertise to
provide the best services. In fact, such large national
laboratories currently use AFIP consultation services. Further,
DOD pathologists we interviewed expressed concern for their
patients' care with respect to whether DOD would obtain the best
subspecialty consultations possible.
DOD has formed a working group, which met for the first time in
August 2007, to address issues pertaining to obtaining
consultations. This group includes representatives from the
Offices of the Surgeons General of the Army, Navy, and Air Force,
as well as other DOD and VA officials. According to DOD officials,
the workgroup spent its first meeting identifying the challenges
faced by DOD in obtaining needed expertise but had not yet
developed specific options to address the challenges.
Research Could Be Affected Depending on How DOD Plans to Populate,
Maintain, and Use the Repository in the Future
Because DOD has not developed its strategy regarding how it will
populate, maintain, and use the repository, some pathologists we
interviewed were concerned about the future of the repository and
whether it would continue to be a viable research tool. Recently,
USUHS awarded a contract to study the usefulness of the pathology
material in the repository.^35 According to DOD, once that study
is completed in October 2008, USUHS plans to convene a panel of
experts to develop a blueprint on how to use the repository for
research, and then will likely contract for development of a
detailed plan on how to best populate, manage, and use the
repository. USUHS does not intend to finalize key decisions until
that process is complete.
USUHS officials told us that one of the challenges they face in
the future is how they will populate pathology material in the
repository in order to maintain its viability as a research tool.
They explained that AFIP generally populates its repository
through pathology material obtained from its consultation
services. As a result, the repository includes material from the
DOD, VA, and civilian populations. Additionally, AFIP's
Radiologic-Pathologic Correlation course has historically
contributed to the growth of pathology material in the repository
because students, who are primarily civilians, are required to
submit samples to AFIP that have pathologic significance. We
estimate that the repository gains approximately 1,200 to 2,400
samples per year from students attending this course. Pathologists
we interviewed explained that the value of the material in the
repository is related to the number of cases it accumulates for a
particular disease. That is, in order for a researcher to be able
to identify the characteristic patterns of a disease allowing for
its diagnosis and treatment, there must first be a sufficient
number of cases of the particular disease. USUHS officials told us
that due to the large volume of cases that AFIP accumulated in the
repository, including complex cases, researchers can currently
conduct studies of considerable sample size. Thus, the manner in
which USUHS plans to continue to accumulate material in the
repository can influence the pace of research.
Because USUHS does not provide pathology consultations, in the
absence of civilian consultations it will need to develop other
strategies to populate the repository. The strategy that USUHS
officials discussed with us was to populate the repository with
specimens from military hospitals. Populating the repository in
this manner, however, could skew the repository since military
hospitals generally draw patients that are largely young, male,
and active. This could decrease the usefulness of the repository,
ultimately affecting the breadth of research. As a result, it is
important that USUHS develop a strategy to determine how it will
populate the repository, considering both the quantity of
pathology material for each disease as well as the quality and
type of material from which it draws.
^35The study of the material in the repository would include a review of
the physical tissue samples (i.e., clinical records, blocks of tissue
embedded in paraffin, slides, and gross samples of tissue) and the quality
of the linkage between the medical record and tissue samples.
DOD, VA, and civilian pathologists we interviewed also recognize
that proper maintenance of pathology material is necessary for
retaining the repository's optimal usefulness. Specifically, as
medical knowledge of tumors and other conditions evolves, material
requires reclassification by pathologists with subspecialty
expertise in order to be useful. As such, repositories can become
useless without continuous update and evaluation. Officials from
academic centers that we spoke with said that the failure to
preserve, maintain, and update the repository would be a
tremendous loss to pathology, and general medicine overall. USUHS
officials said that having staff pathologists with subspecialty
expertise responsible for properly classifying pathology material
is important to the repository's viability. USUHS discussed with
us that it may employ about 10 to 12 pathologists with
subspecialty expertise who would be responsible for reclassifying
material in the repository as needed.
USUHS officials expressed a desire to expand the use of the
repository to others outside of DOD--such as pharmaceutical
companies and cooperative ventures with other academic
institutions--so that the repository's role in general medical
research could continue and benefit the general population.
However, USUHS officials said that they first need to determine
policy, financial, and legal ramifications, such as patient
privacy issues, before they make any decisions regarding research
access to the repository assets. USUHS officials also told us that
the pathologists they hire would have access to pathology material
in the repository and would also be responsible for conducting
militarily relevant research.
Conclusions
AFIP is a noted institution that has provided pathology expertise
in a range of subspecialty areas, and its customers value the
services that it provides. Congress has mandated that DOD provide
a detailed plan on disestablishing AFIP by December 2007, which
gives DOD an opportunity to address potential challenges involved
with closing the facility. DOD awarded a contract to study the
usefulness of the material in the repository, which it anticipates
to be completed by the end of 2008. DOD anticipates using the
study, a subsequent panel of experts, and a possible second
contract to develop a detailed implementation plan to help make
decisions on how the repository will be managed. As part of its
planning process, it is critical for DOD's plan to go beyond the
steps to terminate, relocate, or outsource AFIP's services and
include implementation strategies that detail how it will organize
consultation services and manage the repository in the future. DOD
has not yet developed these strategies--strategies that could help
mitigate potential negative impacts of disestablishing AFIP and
facilitate a smooth transition as DOD looks to other sources for
obtaining high-quality pathology services.
Recommendations for Executive Action
As part of DOD's initiative to develop a plan for disestablishing
AFIP, we are making three recommendations to the Secretary of
Defense that could help mitigate potential negative impacts of
disestablishing AFIP.
o We recommend that the Secretary of Defense include in the
December 2007 plan to Congress implementation strategies for how
DOD will use existing in-house pathology expertise available
within MTFs, identify and obtain needed consultation services from
subspecialty pathologists with appropriate expertise through the
PMO in a timely manner, and solidify the source and organization
of funds to be used for outsourced consultation services.
o Within 6 months of completion of DOD's study regarding the
usefulness of the pathology material in the repository that is to
be finished in October 2008, the Secretary should require USUHS to
provide Congress with information on the status of the
repository's assets and their potential for research use.
o Prior to USUHS assuming responsibility for the repository, the
Secretary should provide a report to Congress on its
implementation strategies for how it will populate, manage, and
use the repository in the future. The implementation strategies
should include information on how USUHS intends to use pathology
expertise to manage the material, obtain pathology material from a
wide variety of individuals, maximize availability of the
repository for research through cooperative ventures with other
academic institutions, and assist interested groups--if any--in
supporting the continuation of educational services, such as the
Radiologic-Pathologic Correlation course.
Agency Comments and Our Evaluation
DOD and VA provided written comments on a draft of this report,
included in appendix IV and appendix V. In commenting on a draft
of this report, DOD concurred with the report's findings and
conclusions and fully concurred with our recommendation for DOD to
include its implementation strategies for organizing future
pathology consultation services in its December 2007 plan to the
Congress. However, DOD partially concurred with the recommendation
to report to the Congress within 6 months of completing its study
on the viability of the repository. Specifically, DOD indicated
that USUHS would not be in a position to report its strategies on
managing the repository until further work was completed. As a
result, we modified our recommendation to limit the reporting
requirement to information on the viability of material in the
repository and its usefulness for research. We also added another
recommendation that DOD should report to Congress at a later date
on USUHS's planned strategies for managing the repository. In its
written comments, VA agreed that the draft report was factually
accurate, but indicated that it did not fully capture the
essential nature of AFIP's services to VA and DOD or fully address
the impact of its closing. We believe that we provided a balanced
assessment of AFIP's services and the impact of its closing.
In its comments, DOD agreed with the description of the challenges
it faces in developing new approaches to obtaining pathology
expertise through the PMO and managing the repository to ensure
that it remains a rich resource for civilian and military
research. DOD emphasized that it was in the process of developing
alternative strategies that would be coordinated internally and
with VA to ensure that the strategies would meet DOD's needs,
assist the VA, and be in accordance with BRAC recommendations. DOD
concurred with our recommendation that the Secretary of Defense
should include in the December 2007 plan to Congress
implementation strategies for how DOD will use existing in-house
pathology expertise available within MTFs, identify and obtain
needed consultations from subspecialty pathologists with
appropriate expertise through the PMO in a timely manner, and
solidify the source and organization of funds to be used for
outsourced consultation services. In addition, DOD agreed that the
Secretary of Defense should submit a plan to Congress within 6
months of completion of the repository evaluation contract to
provide information on the status of pathology material in it and
its research potential. However, DOD indicated that the results of
the evaluation contract will likely result in another contract to
help develop a detailed strategy on how USUHS will populate,
manage, and use the repository. Therefore, DOD will not be able to
report on how USUHS will populate, manage, and use the repository
within 6 months of completion of the repository evaluation
contract and did not concur with that portion of the draft
recommendation. Given this, we modified our recommendations in
this report to reflect the steps DOD anticipates taking.
Specifically, we separated the recommendations to address
reporting on the viability of the repository material and the
strategies for its maintenance and use.
In commenting on a draft of this report, VA indicated that the
report was factually accurate, but did not sufficiently describe
the potential impact associated with closing AFIP. VA focused on
five concerns--DU testing, stagnation of the repository,
difficulties in replacing AFIP's consultation services and
obtaining them through the PMO, potential impact on patient care,
and the potential costs to replace existing services.
o VA commented that AFIP's testing of DU and other types of
potentially harmful embedded fragments was essential to providing
quality health care to recently injured veterans. VA indicated
that our report did not sufficiently emphasize the importance of
these AFIP services. While the report clearly states that DOD is
considering retaining DU testing, we added additional text in this
report to highlight VA's concerns, including those about testing
other types of potentially harmful embedded fragments.
o VA also indicated that the repository contained a large archive
of veterans' pathology specimens that would be invaluable for
future clinical and research endeavors and expressed concern that
DOD will allow the repository to stagnate upon closure of AFIP.
Our report acknowledges the importance of the repository to
veterans' care. This is why we discussed the challenges of
maintaining a viable repository in the report and made a specific
recommendation that DOD provide information on future plans for
it.
o Regarding consultation services, VA expressed concerns that
other institutions may not have the capacity to absorb AFIP's
workload; some types of services might not be available; and
obtaining services through the PMO may adversely affect timeliness
and make it more complex and inefficient for local facilities to
obtain pathology services. In our report, we discussed such
concerns and stated that DOD faces challenges in obtaining
expertise similar to what AFIP offered. As a result, we
recommended that DOD report to the Congress on how it would
address these challenges and obtain pathology services in the
future.
o VA stated that the report did not fully discuss the impact of
closing AFIP on patient care--especially the significance of
changing diagnoses and of providing timely services. We disagree.
The draft report clearly states that changing a diagnosis can lead
to different treatment and, ultimately, a different outcome for
the patient. The report also states that timeliness is important
because it can affect patient treatment and outcomes. VA appears
to assume that DOD will not be able to obtain timely and quality
consultative services through the PMO. In the report, we stated
that obtaining quality consultation services in a timely manner
through the PMO is one of the challenges that DOD would have to
address. Until DOD develops its strategies, we would not have a
basis to determine whether it would be likely to meet this
challenge.
o VA commented on the potential high cost in procuring alternative
sources for AFIP's services. We did not conduct an overall
assessment of whether it would cost DOD more to obtain
consultations from other sources than it would to maintain AFIP.
DOD considered costs when developing its recommendation to the
BRAC commission to outsource consultations. However, as we have
reported previously, implementing other BRAC recommendations has
led to lower cost savings than DOD had estimated.^36 Regarding the
costs for VA, we state in our report that earlier studies had
found that the costs of the services that AFIP provided to VA
exceeded the value of the paid positions VA provided in exchange.
AFIP officials indicated that this continued to be true in fiscal
year 2007. As a result, depending on how and where VA obtains
consultation services, its costs could increase.
As agreed with your offices, unless you publicly announce its
contents earlier, we plan no further distribution of this report
until 30 days from this date. At that time, we will send copies of
this report to the Secretary of Defense, the Secretary of VA,
appropriate congressional committees, and other interested
parties. We will also make copies available to others upon
request. In addition, the report will be available at no charge on
GAO's Web site at [39]http://www.gao.gov . If you or your staff
have any questions about this report please contact me at (202)
512-7114 or [40][email protected] . 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 major contributions to this report are
listed in appendix VI.
^36GAO, Military Base Realignments and Closures: Observations Related to
the 2005 Round, [41]GAO-07-1203R (Washington, D.C.: Sept. 6, 2007).
Randall B. Williamson
Director, Health Care
Appendix I: Scope and Methodology
To describe key services that the Armed Forces Institute of
Pathology (AFIP) provides to the Department of Defense (DOD), the
Department of Veterans Affairs (VA), and civilian communities, we
reviewed recent reports describing AFIP's services and business
practices, including a previous GAO report^1 and an Army Audit
Agency report on AFIP's business plan^2 and a BearingPoint report
on AFIP's capabilities,^3 and other relevant reports, including
some from VA. We also interviewed officials from AFIP, DOD, VA,
the American Registry of Pathology (ARP), pathology associations
such as the College of American Pathologists (CAP), the American
Society for Investigative Pathology, and the Association of
Pathology Chairs, as well as radiology associations, such as the
American College of Radiology and the Canadian Radiology
Association, to collect information on AFIP's core services.
Additionally, we obtained data from AFIP on the services it
provides. To assess the reliability of these data, we interviewed
knowledgeable agency officials and reviewed related documentation.
We determined that the data were sufficiently reliable for the
purposes of this report.
To describe DOD's plans to terminate, relocate, or outsource
services currently provided by AFIP, as required by the Base
Realignment and Closure (BRAC) provision, we interviewed officials
from DOD's Offices of the Surgeons General of the Army, Navy, and
Air Force; the Office of the Assistant Secretary of Defense for
Health Affairs; the Office of the General Counsel; the TRICARE
Management Activity; the Office of the Deputy Under Secretary of
Defense (Installations and Environment); AFIP; and the Uniformed
Services University of the Health Sciences (USUHS). We also
interviewed pathologists from military treatment facilities (MTF)
and VA medical centers. In addition, we reviewed the BRAC business
plan for the Walter Reed Army Medical Center and related
assumptions and analysis that led to the BRAC decisions.
^1GAO, Armed Forces Institute of Pathology: Business Plan's Implementation
Is Unlikely to Achieve Expected Financial Benefits and Could Reduce
Civilian Role, [42]GAO-05-615 (Washington, D.C.: June 30, 2005).
^2U.S. Army Audit Agency, Armed Forces Institute of Pathology, Audit
Report: A-2006-0170-FFH (Alexandria: August 2006).
^3BearingPoint, Review of Armed Forces Institute of Pathology Capabilities
Recommended for Disestablishment by the Defense Base Closure and
Realignment Commission 2005, May 2006.
To assess the potential impacts of disestablishing AFIP on the
military and civilian communities, we interviewed pathologists
from AFIP, ARP, five MTFs and five VA medical centers, as well as
civilian pathologists from four major medical centers. We
interviewed representatives from pathology and radiology
associations, including ARP, CAP, the American Society for
Investigative Pathology, the Association of Pathology Chairs, the
American College of Radiology, and the Canadian Association of
Radiologists, to obtain their views regarding the potential impact
of discontinuing AFIP's core services. In addition, we reviewed
data from various reports and other documents to assess the
potential impact of discontinuing the three key services as AFIP
currently provides. We performed our work from March 2007 through
November 2007 in accordance with generally accepted government
auditing standards.
Appendix II: Maps of the Armed Forces Institute of Pathology's
(AFIP) 2006 Consultations
In 2006, AFIP provided almost half of its consultations for DOD,
with the rest predominantly for VA and civilian physicians. (See
fig. 2 for the 2006 distribution of AFIP's DOD consultations, fig.
3 for its VA consultations, and fig. 4 for its civilian
consultations.)
Figure 2: AFIP's DOD Consultations for 2006
Figure 3: AFIP's VA Consultations for 2006
Figure 4: AFIP's Civilian Consultations for 2006
Appendix III: Description of Services Performed by the Armed Forces
Institute of Pathology (AFIP)
Legal Medicine: Legal Medicine provides consultation, education, and
research on medical legal, quality assurance, and risk management issues
to the Department of Defense (DOD); manages a registry of closed DOD
medical malpractice cases; manages the DOD Centralized Credentials Quality
Assurance System; assists the Uniformed Services University of the Health
Sciences (USUHS) with the masters degree program in Forensic Sciences;
awards continuing medical education (CME) credits in medical legal,
quality assurance, and risk management to nurses and physicians; and
publishes the journals Legal Medicine and Nursing Risk Management.
National Museum of Health and Medicine: The National Museum of Health and
Medicine was established during the Civil War as the Army Medical Museum.
The Museum promotes the understanding of medicine from past, present, and
future, with a special emphasis on American military medicine. It has five
major collections: Anatomical, Historical, Otis Historical Archives, Human
Developmental Anatomy Center, and Neuroanatomical, which are estimated to
contain more than 24 million objects.
Repository: The National Pathology Repository contains approximately 3
million case files and associated paraffin blocks, microscopic glass
slides, and formalin-fixed tissue specimens. Tens of thousands of cases
are added to the repository each year. Staff code all material for future
research use.
The Office of the Armed Forces Medical Examiner, DNA (deoxyribonucleic
acid) Registry, and Accident Investigation: The Office of the Armed Forces
Medical Examiner conducts scientific forensic investigations for
determining the cause and manner of death of members of the Armed Forces
and of civilians whose deaths come under exclusive federal jurisdiction.
The office provides consultative services in forensic pathology, forensic
toxicology, forensic anthropology, and DNA technology, as well as on-site
medical legal investigations of military accidents. It is the only federal
resource of its kind, so other federal agencies frequently use its
services. The DOD DNA Registry is at the forefront of nuclear and
mitochondrial DNA technology, supports the Office of the Armed Forces
Medical Examiner in identification, and serves as the repository for
specimens obtained from military personnel to be used for identification.
Enlisted histology technician training: The Tri-Service School of
Histotechnology is the only military histopathology training program,
according to a DOD official. It consists of 180 training days in the
technical operations of anatomic pathology. Training includes instruction
in the theory and application of histotechnology and practical training in
the fixation, processing, embedding, microtomy, and staining of tissue
specimens prior to examination by a pathologist. The curriculum also
includes instruction and practical experience as a postmortem examination
(autopsy) assistant.
Program Management Office (PMO): The PMO will be newly established to
coordinate pathology results, contract administration, and quality
assurance and control of DOD second-opinion consults worldwide.
DOD Veterinary Pathology Residency Program: The DOD Veterinary Pathology
Residency Program is a 3-year postdoctoral training program. Residents are
involved in consultation, education, and research during the program. The
residency culminates in a 2-day examination given by the American College
of Veterinary Pathologists, and successful completion of this examination
results in board certification in veterinary anatomic pathology.
Automated Central Tumor Registry: The Automated Central Tumor Registry
provides the uniformed services MTFs with the capability to compile,
track, and report cancer data on DOD beneficiaries. The objective of the
registry is to maintain a research quality database for cancer reporting
that supports outcome analysis, referral patterns, trend analysis,
statistical reporting, health care analysis, epidemiology, and uniform
data collection and tracking.
Center for Clinical Laboratory Medicine: The Center for Clinical
Laboratory Medicine directs the operation of the DOD Clinical Laboratory
Improvement Program, as defined by DOD Instruction 6440.2 and Public Law
No. 100-578; administers law and federal policy for military medical
laboratory operations in peace, contingency, and wartime, ensuring that no
restrictions or cessation of laboratory services impedes DOD mission
requirements; and acts as gatekeeper for DOD and Centers for Disease
Control and Prevention (CDC) initiatives to develop a biological warfare
detection and response system, that is, National Laboratory Response
Network.
Patient Safety Center: The Patient Safety Center manages a comprehensive
patient safety data registry for DOD. The DOD Patient Safety Registry is a
database that gathers standardized clinically relevant information about
all instances and categories of actual events and close calls. This
registry is used to identify and provide feedback on systemic patterns and
practices that place DOD patients at risk, and thereby it stimulates,
initiates, and supports local interventions designed to reduce risk of
errors and to protect patients from inadvertent harm. The Patient Safety
Center publishes DOD Patient Safety Alerts, and it produced the first
Patient Safety Toolkit targeting patient fall reduction.
Diagnostic telepathology: The practice of pathology involves using
telecommunications to transmit data and images between two or more sites
remotely located from each other, according to a DOD official. The data
include clinical information about the patient, such as signs, symptoms,
treatment, and response; gross description of the surgical specimen(s);
and digital images of the processed specimen. These data are transmitted
electronically, allowing a pathologist practicing in a geographically
distant site to consult another pathologist for a second opinion, or to
consult other pathologists who are experts on particular disease
processes.
Biodefense Project - The Joint Biological Agent Identification and
Diagnostic System: The Joint Biological Agent Identification and
Diagnostic System pertains to a rapid identification and diagnostic
confirmation of biological agent exposure or infection, according to a DOD
official. The standalone system consists of a portable unit to perform
sample analysis, a laptop computer for readout display and assay reagent
test kits to identify multiple biological warfare agents, infectious
disease agents, and biological toxins.
Biodefense Project - The Critical Reagent Program: The Critical Reagent
Program provides bulk quantities of DNA extracted from selected biological
threat agents, according to a DOD official. These are then used to develop
validated, high-quality immunological and DNA-based biodetection reagents
to support different biological warfare agent detector platforms.
Reserve Biological Select Agent Inventory: The Reserve Biological Select
Agent Inventory is registered with CDC and with the Army Medical Command,
and includes over 1,500 strains of controlled biological select agents and
toxins, according to a DOD official. These are stored in freezers in
secure Biosafety Laboratory level 3 areas of AFIP. Storage, use, and
transfer of any agents or toxins is strictly controlled and regulated by
CDC and Army regulations.
Depleted uranium (DU) testing: DU Urine Testing supports medical
surveillance programs by measuring the levels of uranium in patients'
urine and identifies the specific source of exposure by accurately
measuring uranium isotopic ratios, according to a DOD official. DU Testing
in Body Fluids and Tissue provides chemical analysis of embedded DU
fragments in tissues removed from shrapnel wounds.
Cystic fibrosis testing: A test for cystic fibrosis is one of several
tests for genetically inherited diseases that are recommended by the
Department of Health and Human Services' Health Resources and Services
Administration and the American College of Medical Genetics. AFIP ceased
cystic fibrosis testing on June 1, 2007. All DOD cystic fibrosis tests are
currently being performed by commercial labs or other DOD labs.
Appendix IV: Comments from the Department of Defense
Appendix V: Comments from the Department of Veterans Affairs
Appendix VI: GAO Contact and Staff Acknowledgments
GAO Contact
Randall B. Williamson, (202) 512-7114 or [43][email protected]
Acknowledgments
In addition to the contact named above, Sheila Avruch, Assistant Director;
Adrienne Griffin; Cathy Hamann; Nora Hoban; Jasleen Modi; Carolina Morgan;
and Andrea Wysocki made key contributions to this report.
Related GAO Products
Military Base Realignments and Closures: Transfer of Supply, Storage, and
Distribution Functions from Military Services to Defense Logistics Agency.
[44]GAO-08-121R . Washington, D.C.: October 26, 2007.
Defense Infrastructure: Challenges Increase Risks for Providing Timely
Infrastructure Support for Army Installations Expecting Substantial
Personnel Growth. [45]GAO-07-1007 . Washington, D.C.: September 13, 2007.
Military Base Realignments and Closures: Plan Needed to Monitor Challenges
for Completing More Than 100 Armed Forces Reserve Centers. [46]GAO-07-1040
. Washington, D.C.: September 13, 2007.
Military Base Realignments and Closures: Observations Related to the 2005
Round. [47]GAO-07-1203R . Washington D.C.: September 6, 2007.
Military Base Closures: Projected Savings from Fleet Readiness Centers
Likely Overstated and Actions Needed to Track Actual Savings and Overcome
Certain Challenges. [48]GAO-07-304 . Washington, D.C.: June 29, 2007.
Military Base Closures: Management Strategy Needed to Mitigate Challenges
and Improve Communication to Help Ensure Timely Implementation of Air
National Guard Recommendations. [49]GAO-07-641 . Washington, D.C.: May 16,
2007.
Military Base Closures: Opportunities Exist to Improve Environmental
Cleanup Cost Reporting and to Expedite Transfer of Unneeded Property.
[50]GAO-07-166 . Washington, D.C.: January 30, 2007.
Military Bases: Observations on DOD's 2005 Base Realignment and Closure
Selection Process and Recommendations. [51]GAO-05-905 . Washington, D.C.:
July 18, 2005.
Military Bases: Analysis of DOD's 2005 Selection Process and
Recommendations for Base Closures and Realignments. [52]GAO-05-785 .
Washington, D.C.: July 1, 2005.
Armed Forces Institute of Pathology: Business Plan's Implementation Is
Unlikely to Achieve Expected Financial Benefits and Could Reduce Civilian
Role. [53]GAO-05-615 . Washington, D.C.: June 30, 2005.
Military Base Closures: Updated Status of Prior Base Realignments and
Closures. [54]GAO-05-138 . Washington, D.C.: January 13, 2005.
Military Base Closures: Assessment of DOD's 2004 Report on the Need for a
Base Realignment and Closure Round. [55]GAO-04-760 . Washington, D.C.: May
17, 2004.
Military Base Closures: Observations on Preparations for the Upcoming Base
Realignment and Closure Round. [56]GAO-04-558T . Washington, D.C.: March
25, 2004.
(290622)
To view the full product, including the scope
and methodology, click on [57]GAO-08-20 .
For more information, contact Randall B. Williamson at (202) 512-7114 or
[email protected].
Highlights of [58]GAO-08-20 , a report to the Committee on Health,
Education, Labor, and Pensions, U.S. Senate
November 2007
MILITARY BASE REALIGNMENTS AND CLOSURES
Impact of Terminating, Relocating, or Outsourcing the Services of the
Armed Forces Institute of Pathology
The 2005 Base Realignment and Closure (BRAC) provision required the
Department of Defense (DOD) to close the Armed Forces Institute of
Pathology (AFIP). GAO was asked to address the status and potential impact
of implementing this BRAC provision. This report discusses (1) key
services AFIP provides to the military and civilian communities; (2) DOD's
plans to terminate, relocate, or outsource services currently provided by
AFIP; and (3) the potential impacts of disestablishing AFIP on military
and civilian communities. New legislation requires DOD to consider this
GAO report as it develops its plan for the reorganization of AFIP. GAO
reviewed DOD's plans, analysis, and other relevant information, and
interviewed officials from the public and private sectors.
[59]What GAO Recommends
GAO recommends DOD report to Congress on (1) its strategies for organizing
consultation services; (2) the repository's assets and their potential
use; and (3) its strategies for using the repository. DOD generally
concurred with GAO's findings and conclusions. GAO has modified its
recommendations to reflect concerns DOD raised about additional steps it
needs to take before it can report on its strategies for using the
repository. VA stated that GAO's report was factually accurate, but
believed that it did not sufficiently describe the impact of closing AFIP.
GAO believes that this report provides a balanced assessment of AFIP's
services and the impact of its closing.
AFIP pathologists perform three key services--diagnostic consultations,
education, and research--primarily for physicians from DOD, the Department
of Veterans Affairs (VA), and civilian institutions. AFIP provides
consultations when physicians cannot make a diagnosis or are unsure of
their initial diagnosis. About half of its 40,000 consultations in 2006
were for DOD physicians, and the rest were nearly equally divided between
VA and civilian physicians. AFIP's educational services train physicians
in diagnosing the most difficult-to-diagnose diseases. Civilian physicians
use these services more extensively than military physicians. In addition,
AFIP pathologists collaborate with others on research applicable to
military operations and general medicine, often using material from AFIP's
repository of tissue specimens to gain a better understanding of disease
diagnosis and treatment.
To implement the 2005 BRAC provision, DOD plans to terminate most services
currently provided by AFIP and is developing plans to relocate or
outsource others. DOD plans to outsource some diagnostic consultations to
the private sector through a newly established office and use its
pathologists for consultations when possible. With the exception of two
courses, DOD does not plan to retain AFIP's educational program. DOD also
plans to halt AFIP's research and realign the repository, which is AFIP's
primary research resource. The BRAC provision allows DOD flexibility to
retain services that were not specifically addressed in the provision. As
a result, DOD will retain four additional AFIP services and is considering
whether to retain six others. DOD had planned to begin implementation of
the BRAC provision related to AFIP in July 2007 and complete action by
September 2011, but statutory requirements prevent DOD from reorganizing
or relocating AFIP functions until after DOD submits a detailed plan and
timetable for the proposed implementation of these changes to
congressional committees no later than December 31, 2007. Once the plan
has been submitted, DOD can resume reorganizing and relocating AFIP.
Discontinuing, relocating, or outsourcing AFIP services may have minimal
impact on DOD, VA, and civilian communities because pathology services are
available from alternate sources, but a smooth transition depends on DOD's
actions to address the challenges in developing new approaches to
obtaining pathology expertise and managing the repository. For
consultations, these challenges are to determine how to use existing
pathology resources, obtain outside expertise, and ensure coordination and
funding of services to avoid disincentives to quality care. While DOD has
begun to identify the challenges, it has not developed strategies to
address them. Similarly, whether the repository will continue to be a rich
resource for military and civilian research depends on how DOD populates,
maintains, and provides access to it in the future, but DOD has not
developed strategies to address these issues. DOD contracted for a study,
due to be completed in October 2008, of the usefulness of the material in
the repository. DOD plans to use this study to help make decisions about
managing the repository.
GAO's Mission
The Government Accountability Office, the audit, evaluation, and
investigative arm of Congress, exists to support Congress in meeting its
constitutional responsibilities and to help improve the performance and
accountability of the federal government for the American people. GAO
examines the use of public funds; evaluates federal programs and policies;
and provides analyses, recommendations, and other assistance to help
Congress make informed oversight, policy, and funding decisions. GAO's
commitment to good government is reflected in its core values of
accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony
The fastest and easiest way to obtain copies of GAO documents at no cost
is through GAO's Web site ( [60]www.gao.gov ). Each weekday, GAO posts
newly released reports, testimony, and correspondence on its Web site. To
have GAO e-mail you a list of newly posted products every afternoon, go to
[61]www.gao.gov and select "E-mail Updates."
Order by Mail or Phone
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent of
Documents. GAO also accepts VISA and Mastercard. Orders for 100 or more
copies mailed to a single address are discounted 25 percent. Orders should
be sent to:
U.S. Government Accountability Office 441 G Street NW, Room LM Washington,
DC 20548
To order by Phone: Voice: (202) 512-6000
TDD: (202) 512-2537
Fax: (202) 512-6061
To Report Fraud, Waste, and Abuse in Federal Programs
Contact:
Web site: [62]www.gao.gov/fraudnet/fraudnet.htm
E-mail: [63][email protected]
Automated answering system: (800) 424-5454 or (202) 512-7470
Congressional Relations
Gloria Jarmon, Managing Director, [64][email protected] , (202) 512-4400
U.S. Government Accountability Office, 441 G Street NW, Room 7125
Washington, DC 20548
Public Affairs
Chuck Young, Managing Director, [65][email protected] , (202) 512-4800 U.S.
Government Accountability Office, 441 G Street NW, Room 7149 Washington,
DC 20548
References
Visible links
36. http://www.gao.gov/cgi-bin/getrpt?GAO-05-615
37. http://www.gao.gov/cgi-bin/getrpt?GAO-05-615
38. http://www.gao.gov/cgi-bin/getrpt?GAO-05-615
39. http://www.gao.gov/
40. mailto:[email protected]
41. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1203R
42. http://www.gao.gov/cgi-bin/getrpt?GAO-05-615
43. mailto:[email protected]
44. http://www.gao.gov/cgi-bin/getrpt?GAO-08-121R
45. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1007
46. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1040
47. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1203R
48. http://www.gao.gov/cgi-bin/getrpt?GAO-07-304
49. http://www.gao.gov/cgi-bin/getrpt?GAO-07-641
50. http://www.gao.gov/cgi-bin/getrpt?GAO-07-166
51. http://www.gao.gov/cgi-bin/getrpt?GAO-05-905
52. http://www.gao.gov/cgi-bin/getrpt?GAO-05-785
53. http://www.gao.gov/cgi-bin/getrpt?GAO-05-615
54. http://www.gao.gov/cgi-bin/getrpt?GAO-05-138
55. http://www.gao.gov/cgi-bin/getrpt?GAO-04-760
56. http://www.gao.gov/cgi-bin/getrpt?GAO-04-558T
57. http://www.gao.gov/cgi-bin/getrpt?GAO-08-20
58. http://www.gao.gov/cgi-bin/getrpt?GAO-08-20
60. http://www.gao.gov/
61. http://www.gao.gov/
62. http://www.gao.gov/fraudnet/fraudnet.htm
63. mailto:[email protected]
64. mailto:[email protected]
65. mailto:[email protected]
*** End of document. ***