Military Physicians: DOD's Medical School and Scholarship Program
(Chapter Report, 09/29/95, GAO/HEHS-95-244).

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-95-244
     TITLE:  Military Physicians: DOD's Medical School and Scholarship 
             Program
      DATE:  09/29/95
   SUBJECT:  Physicians
             Student aid programs
             Medical education
             Military training
             Defense contingency planning
             Cost effectiveness analysis
             Health care personnel
             Military officers
             Attrition rates
             Medical schools
IDENTIFIER:  Armed Forces Health Professions Scholarship Program
             DOD Combat Casualty Care Course
             DOD Counter Narcotics Tactical Operations Medical Support 
             Program
             DOD Wound Data and Munitions Effectiveness Team
             Persian Gulf War
             Hurricane Andrew
             Civilian Health and Medical Program of the Uniformed 
             Services
             CHAMPUS
             DOD TRICARE Program
             
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Cover
================================================================ COVER


Report to the Congressional Requesters

September 1995

MILITARY PHYSICIANS - DOD'S
MEDICAL SCHOOL AND SCHOLARSHIP
PROGRAM

GAO/HEHS-95-244

Military Physicians

(101462)


Abbreviations
=============================================================== ABBREV

  AAMC - Association of American Medical Colleges
  CHAMPUS - Civilian Health and Medical Program of the Uniformed
     Services
  C4 - Combat Casualty Care Course
  DOD - Department of Defense
  CBO - Congressional Budget Office
  EEO - equal employment opportunity
  GME - graduate medical education
  GPA - grade point average
  HEHS - Health, Education, and Human Services Division
  HPSP - Health Profession Scholarship Program
  IG - inspector general
  LCME - Liaison Committee on Medical Education
  MCAT - Medical College Admissions Test
  NIH - National Institutes of Health
  NPR - National Performance Review
  NSIAD - National Security and International Affairs Division
  OMB - Office of Management and Budget
  OSD - Office of the Secretary of Defense
  PA&E - Program Analysis and Evaluation
  ROTC - Reserve Officer Training Corps
  USMLE - United States Medical Licensing Examination
  USU - Uniformed Services University of the Health Sciences

Letter
=============================================================== LETTER


B-265758

September 29, 1995

The Honorable Strom Thurmond
Chairman
The Honorable Sam Nunn
Ranking Minority Member
Committee on Armed Services
United States Senate

The Honorable Floyd D.  Spence
Chairman
The Honorable Ronald V.  Dellums
Ranking Minority Member
Committee on National Security
House of Representatives

Enclosed is our report, Military Physicians:  DOD's Medical School
and Scholarship Program (GAO/HEHS-95-244), which was mandated by the
National Defense Authorization Act for Fiscal Year 1995.  This report
provides information on the Department of Defense's Uniformed
Services University of the Health Sciences and the Health Profession
Scholarship Program.  Among other things, the report addresses the
costs of obtaining physicians through each of these sources and how
physicians obtained through each are prepared to meet the special
needs of military medicine. 

We are sending copies of this report to the Chairman and Ranking
Minority Member of the Senate Committee on Armed Services'
Subcommittee on Personnel, Senator Russell D.  Feingold, other
appropriate congressional committees, the Secretary of Defense, and
other interested parties.  We also will make copies available to
others on request.  If you have any questions about this report,
please call George F.  Poindexter, Assistant Director, at (202)
512-7213.  Other major contributors to this report are Lawrence L. 
Moore, William A.  Schechterly, Michael C.  Williams, and Mona M. 
Zadjura. 

David P.  Baine
Director, Health Care Delivery
 and Quality Issues


EXECUTIVE SUMMARY
============================================================ Chapter 0


   PURPOSE
---------------------------------------------------------- Chapter 0:1

In the 2 decades since its legislative establishment, proposals have
been made to close the Uniformed Services University of the Health
Sciences, the Department of Defense's (DOD) medical school in
Bethesda, Maryland.  Those who propose closing the University assert
that DOD's need for physicians can be met at a lower cost using
physicians educated at civilian medical schools.  Those who propose
retaining the University assert that it is needed to provide a stable
cadre of physicians trained to meet the unique demands of military
medicine. 

Following proposals in 1994 to close the University, the Congress
mandated that GAO review issues related to the University and the
other means through which DOD obtains physicians.\1 Among other
things, GAO was directed to examine (1) the cost of obtaining
military physicians from all sources, (2) the quality of the medical
education provided at the University, (3) how physicians are trained
to meet the needs of military medicine, and (4) retention rate
patterns among the accession programs. 

GAO reviewed prior studies; analyzed data from DOD, the services, and
the University; and held discussions with military and civilian
officials to respond to these issues. 


--------------------
\1 The National Defense Authorization Act for Fiscal Year 1995, (P.L. 
No.  103-337, ï¿½922(c)(1)(4)). 


   BACKGROUND
---------------------------------------------------------- Chapter 0:2

In 1972, Public Law 92-426 established two complementary physician
accession sources:  the Health Profession Scholarship Program and the
University.  Under the scholarship program, DOD pays tuition and
fees, plus a monthly stipend for students enrolled in civilian
medical schools.  In return, the students incur an obligation to
serve a year of active duty service for each year of benefits
received, with a 2-year minimum obligation.  Upon graduation, most
scholarship program participants (regular program participants) go on
active duty and begin graduate medical education (GME) in military
hospitals.  Other scholarship program participants (deferred program
participants) are granted deferments while they pursue civilian GME. 
In 1994, 987 scholarship program participants graduated from medical
school. 

Students at the University enter active military service as medical
students, receive the pay and benefits of an officer at the O-1
level, and incur a 7-year service obligation.  In 1994, 155 medical
students graduated from the University. 

The primary responsibilities of military physicians (regardless of
accession source) are to provide medical support to the forces who
carry out DOD's operational missions and other active duty personnel. 
They also provide health care to nonactive duty beneficiaries.  To
prepare physicians for the practice of military medicine, the
University augments the traditional 4-year medical school education
with readiness training; scholarship program graduates attend
training courses offered by the services. 

In 1990, the DOD Inspector General reported on the adequacy of the
University's management oversight and control of its diverse
operations.  The Inspector General's report recommended corrective
actions in six categories of those operations and closed the
inspection in October 1994 based on the University's corrective
actions.  Appendix IV contains a detailed discussion of the Inspector
General's findings and the University's actions. 


   RESULTS IN BRIEF
---------------------------------------------------------- Chapter 0:3

Determining the most cost effective way to educate and retain
military physicians depends on the cost elements included and the
unit of analysis used to measure cost.  By most measures, the
University is a more costly way to educate and retain military
physicians.  For example, on a per graduate basis, GAO's analysis
shows that the University is the most expensive source for educating
and retaining military physicians when considering DOD and total
federal costs.  When costs are distributed over the expected years of
military physicians' service, the University remains more costly when
DOD costs are considered.  However, when all federal costs are
considered, the University is nearly equal to the cost of the regular
scholarship program and lower than the cost of the deferred
scholarship program.  This difference occurs because University
graduates are expected to have much longer military careers and the
University receives much less non-DOD federal support than civilian
medical schools. 

GAO's analysis shows that the University provides a medical education
that compares well with that of other U.S.  medical schools. 
Traditional measures of quality place the University within the
midrange of medical schools nationwide and its graduates at or above
other military physicians.  In addition, to help meet standards
required for accreditation as an academic institution, the University
provides education and training for other health care and related
professions and engages in research, consultation, and archival
activities.  These activities, which do not directly contribute to
the education of military physicians, involve University faculty and
staff.  University officials believe that DOD would continue to
conduct these activities even if the University is closed and
estimated their value to be about $18.6 million--a figure which GAO
did not validate. 

University graduates begin their military medical careers with more
readiness training than their peers, but the significance of the
additional training is unclear.  The commanders of military medical
units that GAO contacted believe that University graduates are, at
least initially, better prepared than other physicians to address the
special needs of military medicine.  However, due to the absence of
objective measures, no conclusive evidence exists that University
graduates are better prepared to meet the needs of military medicine
than their civilian-educated peers.  The services have not assessed
the impact of readiness training and a thorough assessment is needed
to determine the type and amount of such training that military
physicians need. 

GAO's review of DOD retention data suggests that University graduates
are likely to provide DOD with a cadre of experienced physician
career officers.  Scholarship program physicians, who comprise the
majority of new physician accessions, are retained in the military
for shorter periods, on average, than University graduates. 

However, given the changes in operational scenarios and DOD's
approach for delivering peacetime health care, new assessments of the
military's physician needs and the means to acquire and retain such
physicians are in order.  For example, if DOD continues to need a
cadre of experienced career physicians, alternative strategies such
as an additional scholarship option with a longer service obligation
could be considered as a potentially less expensive way to increase
the length of selected military physicians' careers. 

As the Congress makes decisions regarding both physician accession
programs, it will need information not only about the programs'
relative costs but also about their effects on the short- and
long-term requirements for military physicians and the value of the
other University activities. 


   PRINCIPAL FINDINGS
---------------------------------------------------------- Chapter 0:4


      THE UNIVERSITY IS THE
      COSTLIEST PHYSICIAN SOURCE
      ON A PER GRADUATE BASIS
-------------------------------------------------------- Chapter 0:4.1

GAO's analysis shows that on a per graduate basis, the University is
the most expensive source of military physicians when considering DOD
costs and total federal costs.  With DOD education and retention
costs of about $3.3 million, the cost of a University graduate is
more than 2 times greater than the $1.5 million cost for a regular
scholarship program graduate and about 5 times greater than the
$659,000 cost for a deferred scholarship program graduate.  When all
federal costs are considered, the cost of a University graduate is
about $3.4 million, about 1.9 times more costly than regular
scholarship program graduates ($1.8 million) and more than 2.7 times
more costly than deferred scholarship program graduates ($1.2
million).  Figure 1 depicts these relationships. 

   Figure 1:  Per Graduate Costs
   for University and Scholarship
   Program Participants

   (See figure in printed
   edition.)


      UNIVERSITY COSTS ARE
      COMPARABLE TO SCHOLARSHIP
      COSTS BASED ON EXPECTED
      YEARS OF SERVICE AND ALL
      FEDERAL COSTS
-------------------------------------------------------- Chapter 0:4.2

The difference in costs between the University and the scholarship
program narrows when costs are amortized over the expected years of
military service for each group because University graduates are
expected to serve nearly twice as long as their regular scholarship
program peers and more than three times as long as deferred
scholarship program physicians.\2 On an expected years of service
basis, DOD's cost to educate and retain a University graduate is
about $176,000 compared with about $150,000 for the regular
scholarship program and about $125,000 for the deferred scholarship
program.  However, when total federal costs are amortized over the
expected years of military service, the costs of University graduates
are more comparable to scholarship program physicians because the
University receives less non-DOD federal support than civilian
medical schools.  University graduates are expected to serve for
about 18.5 years, on average, resulting in a per year federal cost of
about $182,000.  Regular scholarship program physicians, expected to
serve for 9.8 years, on average, have an annual federal cost of about
$181,000, and deferred scholarship program physicians, expected to
serve for 5.3 years, on average, have an annual federal cost of about
$232,000.  Figure 2 shows DOD and federal costs for physicians from
each source based on expected years of military service. 

   Figure 2:  Per Expected Year
   Costs of Service for University
   and Scholarship Program
   Participants

   (See figure in printed
   edition.)


--------------------
\2 Expected years of service is a calculation based on DOD retention
estimates for physicians from each program multiplied by the number
of graduates from each program in 1994.  DOD's retention estimates
are projections based on historical retention data for each program
and the experience of all military physicians.  Actual years of
service for physicians from each accession source may be greater or
less than these projections. 


      THE UNIVERSITY PROVIDES
      QUALITY EDUCATION AND OTHER
      BENEFITS TO DOD
-------------------------------------------------------- Chapter 0:4.3

The University's School of Medicine is fully accredited and its
students have undergraduate grade point averages and admission test
scores that fall within the middle of the ranges for such statistics
for all medical schools.  Post-graduate measures, such as pass rates
for the medical license examination and graduates' performance in
their first year of GME, indicate that the results for University
graduates are equivalent or slightly better than those of other
military physicians. 

To help meet accreditation standards and to advance the practice of
military medicine, the University engages in several activities in
addition to operating its School of Medicine.  These activities
include providing overseas medical personnel required continuing
medical education, serving as the academic affiliate for several
military graduate medical education programs, and offering graduate
education programs for allied health professionals.  The University
has established research and archival programs in such areas as
casualty care, preventive medicine, and psychiatric responses to
trauma and disaster.  University officials point out that if the
University were not performing these roles, other DOD components
would have to be tasked to carry them out. 


   UNIVERSITY STUDENTS RECEIVE
   EXTENSIVE MEDICAL READINESS
   TRAINING, BUT ITS IMPACT IS
   UNCLEAR
---------------------------------------------------------- Chapter 0:5

The University provides training in the special needs of military
medicine as an integral part of its medical school curriculum.  By
the time University students graduate and begin active duty, they
have received at least 784 hours of medical readiness training. 
Other new military physicians take specific medical readiness
training courses once they are on active duty; however, the initial
training they receive is less extensive than that provided to
University graduates. 

Even though graduates of the University begin their military medical
careers with more initial readiness training than other new military
physicians, the significance of the additional training is unclear. 
While the commanders of military medical units that GAO contacted
perceive that physicians from the University are at least initially
better prepared than their civilian educated peers for military
medicine, objective measures of the effects of the University or
other approaches to medical readiness training are not available. 
DOD has not compared the effectiveness of the University approach
with other initial readiness training offered by the services. 
Recent deployments have not comprehensively tested the individual
readiness capabilities of military physicians, and such capabilities
are not routinely assessed in peacetime. 


   RETENTION RATE PATTERNS FOR
   GRADUATES CONSISTENT WITH
   PROGRAM OBJECTIVES
---------------------------------------------------------- Chapter 0:6

DOD's need for physicians has changed as a result of the end of Cold
War scenarios, the emergence of regional threats, and the overall
downsizing of the military in response to budget deficits.  In
addition, DOD has dramatically changed its approach to delivering
medical care to military beneficiaries during peacetime by relying
more heavily on civilian providers to deliver much of that care. 
Although the Department is currently reevaluating its future need for
physicians, it has not reached final conclusions about the number of
physicians needed nor the optimal length of time that physicians
should serve. 

GAO's analysis of DOD retention data shows that University graduates
are likely to meet DOD's needs for an experienced cadre of military
physicians while scholarship program graduates generally have shorter
careers.  Factors such as age, marital status, compensation,
nonphysician duties, and working conditions have been associated with
physician retention.  A key factor in the longer retention of
University graduates, however, appears to be their longer pay-back
obligation.  If the University were closed, the scholarship program
might need to be revised to encourage or require some scholarship
students to stay longer in the military.  For example, one approach
might be a scholarship option with a longer service obligation,
including enhanced military readiness training and, perhaps,
additional benefits. 


   MATTER FOR CONGRESSIONAL
   CONSIDERATION
---------------------------------------------------------- Chapter 0:7

The Administration's National Performance Review has proposed that
the University be closed.  This proposal has presented the Congress
with difficult policy decisions regarding the need for a cadre of
physicians who are likely to become career military officers and the
most appropriate means of retaining those physicians. 

As the Congress makes those decisions, it may wish to consider
requiring DOD to justify both the University and the scholarship
program in the context of DOD's specific short- and long-term
requirements for military physicians, the role of the University and
the scholarship program in satisfying those requirements, and their
relative costs. 


   AGENCY COMMENTS
---------------------------------------------------------- Chapter 0:8

On September 15, 1995, GAO met with the Assistant Secretary of
Defense, Health Affairs, and other DOD officials and with the
President of the University and his top staff to obtain their
comments on a draft of this report. 

The Assistant Secretary stated that the report presents a great deal
of relevant, factual data and reflects a significant research effort. 
In response to GAO's matter for congressional consideration, however,
the Assistant Secretary stated that the Department does not believe
that additional justification is needed for the University and
scholarship program.  Both the Assistant Secretary and University
officials expressed concerns regarding several presentational issues,
such as the use of cost per graduate as a unit of analysis as well as
GAO's treatment of the University's cost-avoidance activities and
contributions to the training and education of physicians for the
unique demands of military medicine.  GAO believes that its findings
are presented in a balanced and objective way.  These issues are
discussed in more detail on page 60.  As a result of these comments
and technical suggestions, GAO has revised the report as appropriate. 


INTRODUCTION
============================================================ Chapter 1

The Department of Defense (DOD) has about 13,700 active duty
physicians, nearly 1,300 of whom entered military service in fiscal
year 1994.\3 About 93 percent of these new physicians entered the
military through the Health Profession Scholarship Program (HPSP) or
through DOD's medical school--the Uniformed Services University of
the Health Sciences (USU)--which were authorized as complementary
programs under the Uniformed Services Health Profession
Revitalization Act of 1972 (P.L.  92-426.)

To acquire physicians through these two programs, DOD incurs either
the costs of providing the participants a medical education plus
student stipends for scholarship participants or military salaries
and benefits for students at the University.  After the participants
graduate from medical school, DOD incurs the costs of physician
ownership--providing graduate medical education (GME)\4 and other
training; salaries, bonuses, and benefits; and retirement pay for
those physicians who remain on active duty for at least 20 years. 

Military physicians are needed to support operational forces during
war or other military operations and to maintain the well-being of
the forces during nonoperational periods.  Military physicians also
provide health care services to nonactive duty beneficiaries. 


--------------------
\3 The services also have about 6,500 physicians in the reserves. 
However, except where indicated, this report addresses issues related
to active duty physician accession programs (the University and the
scholarship program). 

\4 During their fourth year of medical school, students formally
elect the medical specialty area they intend to pursue.  The medical
specialty training programs, which generally take 3 to 7 years to
complete, are referred to as graduate medical education (GME). 
During this time, physicians are generally referred to as interns or
residents. 


   CURRENT PHYSICIAN ACCESSION
   PROGRAMS
---------------------------------------------------------- Chapter 1:1

With the end of the draft in 1972, the military services needed new
means of obtaining active duty physicians.  To address this need,
Public Law 92-426 established two complementary accession
sources--the scholarship program and the University.  In addition to
these sources, the services continue to attract physicians directly
from the private sector.\5 Table 1.1 shows the number of physicians
entering each military service from each accession program for fiscal
years 1992 to 1994. 



                                              Table 1.1
                               
                                Physician Accessions by Source (Fiscal
                                            Years 1992-94)


                                 Air                         Air                         Air
Source            Army  Navy   Force   Total  Army  Navy   Force   Total  Army  Navy   Force   Total
----------------  ----  ----  ------  ------  ----  ----  ------  ------  ----  ----  ------  ------
HPSP\a             351   363     380   1,094   313   373     306     992   313   344     393   1,050
USU\b               69    56      47     172    56    46      48     150    56    48      43     147
Other               49    53     182     284    46    32     102     180    22    45      21      88
 Total 4      69 4  72 6    09 1  ,550 4  15 4  51 4    56 1  ,322 3  91 4  37 4    57 1    ,285
----------------------------------------------------------------------------------------------------
\a Scholarship accessions include current-year graduates and
graduates from previous years who deferred their active-duty service
to participate in civilian GME programs. 

\b Some students take longer than 4 years to complete medical school,
while others drop out for various reasons; hence, the total number of
graduates differs from the average number of students enrolled in
each class (about 160).  In addition, during this same period, 19
University graduates entered the Public Health Service:  6 in 1992, 5
in 1993, and 8 in 1994. 


--------------------
\5 In 1994, about 7 percent of physicians came through programs such
as the Financial Assistance Program, which pays incentives to medical
school graduates specializing in medical disciplines critical for
wartime needs, and through direct recruitment of civilian physicians. 
Because of the small numbers involved, they were not included in the
analyses for this report. 


      HEALTH PROFESSION
      SCHOLARSHIP PROGRAM
-------------------------------------------------------- Chapter 1:1.1

The scholarship program is the largest source for military
physicians.\6 The legislative history of Public Law 92-426 indicates
that the scholarship program was intended to provide the services
with the majority of their physicians, most of whom would not be
expected to make the military a lifetime career.  Under the
scholarship program, the services pay medical school tuition and fees
as well as stipends for civilian medical school students.  In return,
after graduation, program participants must serve 1 year of active
duty military service for each year that they receive benefits with a
2-year minimum obligation.  Scholarship program participants also
incur an obligation to serve in the reserves for a period of time,
which varies depending upon the number of years of benefits received. 
The total obligation of active and reserve duty is 8 years for all
scholarship program participants (not including time spent in GME). 

Upon graduation, most scholarship program participants enter active
duty at the O-3 pay grade (that is, as captains in the Army and Air
Force and as lieutenants in the Navy) and begin their first year of
GME in military medical facilities.  Licensure typically occurs at
the end of that year.  At that point, depending upon the needs of the
service, a scholarship program participant may continue GME or begin
serving as a general medical officer.  Time spent in GME does not
satisfy the commitment incurred as a participant in the scholarship
program; however, such time is credited for retirement purposes. 

Although most scholarship program participants enter active duty upon
graduation from medical school, others are granted a deferment so
that they may pursue GME in the civilian sector.  Upon completion of
their GME, deferred scholarship program participants serve their
active duty obligations, entering active service at the pay grade
they would have attained had they not deferred their military
service.  Of the 987 scholarship program participants who graduated
in fiscal year 1994, 283 were deferred.  Scholarship program
participants who participate in military GME programs are referred to
as regular scholarship program participants.  In fiscal year 1994,
704 regular scholarship program participants entered the military. 

For DOD, the educational costs of acquiring physicians through the
scholarship program include medical school tuition and fees, student
stipends, active duty pay for a 45-day period each year, and program
administration costs.  After graduation, the costs that DOD incurs to
employ these physicians include those for GME (for those graduates
who participate in military GME programs); initial medical readiness
training (including basic officer training); salary, bonuses, and
benefits; and retirement pay for those physicians who remain on
active duty for at least 20 years. 


--------------------
\6 The scholarship program also sponsors students of dentistry,
optometry, and nursing. 


      UNIFORMED SERVICES
      UNIVERSITY OF THE HEALTH
      SCIENCES
-------------------------------------------------------- Chapter 1:1.2

The University also authorized by Public Law 92-426, is DOD's medical
school in Bethesda, Maryland.  According to the legislative history,
the University is intended to provide DOD a group of military
physicians likely to make the military a career. 

When students enter the University's School of Medicine, they begin
active military service with the pay grade of O-1 (that is, as second
lieutenants in the Army and Air Force or ensigns in the Navy) and
receive all benefits associated with active military service.  Upon
graduation, University students are promoted to the grade of O-3 and
begin serving a 7-year obligation.  They might also incur a reserve
obligation of 2 to 6 years (not including time spent in GME). 

On average, the University has enrolled about 160 students each year
since 1981.  Most graduates go into the Army, Navy, or Air Force;
however, a limited number of students each year are sponsored by the
Public Health Service.  For example, of the 155 graduates in 1994, 8
were sponsored by the Public Health Service.  Since its first class
graduated in 1980, the University has produced 2,064 physicians for
the three services and 84 for the Public Health Service. 

For DOD, the educational costs of acquiring physicians through the
University include the costs of student and faculty salaries and
benefits, facility operations and maintenance, and basic officer
training.  After students graduate, DOD incurs the costs of their
GME, salary and benefits, and retirement pay for those who serve at
least 20 years. 


   THE SPECIAL NEEDS OF MILITARY
   MEDICINE
---------------------------------------------------------- Chapter 1:2

Military medicine is not a recognized medical specialty; however,
medical literature we reviewed as well as military and civilian
officials with whom we spoke identified a number of factors that
differentiate the practice of military medicine from the practice of
medicine in civilian settings.  According to these sources, the
primary factors that contribute to the special needs of military
medicine are the objectives of the combat medical care system, the
circumstances and environments in which care is provided, and the
need to understand military operations and procedures.  However, no
consensus exists in DOD or the services regarding the amount or types
of education and training physicians need--in addition to traditional
medical education--to meet the special needs of military medicine. 
Chapter 3 discusses how University and scholarship program graduates
are prepared for the special needs of military medicine. 


      MILITARY MEDICINE EMPHASIZES
      KEEPING TROOPS FIT FOR DUTY
-------------------------------------------------------- Chapter 1:2.1

Practitioners of military medicine concentrate their attention on
preventing and treating illnesses and injuries more commonly
experienced in operational or combat settings.  While similar or
related illnesses, injuries, or health concerns exist in civilian
settings, military medical literature and practitioners state that
some illnesses and injuries lack parallels in civilian settings; thus
special training is necessary to practice medicine in operational
settings in support of combat and noncombat missions.\7

Military medical literature notes that the objectives of the combat
medical care system are different from civilian objectives.  In
civilian circumstances, the physician's objective is to ensure the
welfare of the individual patient.  In contrast, the objective of the
military physician is to "conserve the fighting strength" in order to
ensure the success of the military mission.  To minimize troop losses
to disease and injury both before and during deployment, the military
physician is responsible for identifying the health threats to which
troops are exposed and developing plans to minimize their impact. 
Such preventive medicine programs include immunization, sanitation,
and safety awareness. 


--------------------
\7 For further discussion about military medicine see International
Military and Defense Encyclopedia (Washington, D.C.:  Brassey's,
Inc., 1993); Public Health & Preventive Medicine 13th ed.  (East
Norwalk, Conn:  Appleton & Lange, 1992); and The Oxford Companion to
Medicine, (Oxford:  Oxford University Press, 1986). 


      THE PROVISION OF CARE IN
      COMBAT SETTINGS
-------------------------------------------------------- Chapter 1:2.2

When troops become ill or are injured in combat, the objective of
military physicians is to provide treatment that will permit the
patient's return to duty, if possible, or removal of the patient to a
location where additional care may be provided.  To accomplish this
objective, the combat medical system is organized into echelons, or
different levels of medical support for combat troops.  Echelon 1,
the most far-forward and mobile level of medical support, is
necessarily the most austerely staffed and equipped.  At this level,
minimally injured personnel are treated and returned to combat.  More
serious casualties are evacuated to higher echelons.  Each echelon, 2
through 5, has all the capabilities of the lower echelons, plus
increasingly sophisticated capabilities. 

An essential element of the combat medical system is the practice of
triage, or sorting, which is based on the principle of accomplishing
the greatest good for the greatest number under the circumstances. 
Triage is the process of establishing the priorities for treatment
and evacuation and is necessary in the case of mass casualties in
order to avoid overwhelming the medical resources available.  In such
instances, before providing treatment, medical personnel are required
to place casualties in categories ranging from urgent (those injuries
requiring immediate intervention to prevent death) to expectant
(wounds so severe that survival would be unlikely even if all medical
resources were applied.)


      MEDICAL STAFF ADVISE LINE
      COMMANDERS
-------------------------------------------------------- Chapter 1:2.3

In operational settings, the military physician serves as medical
staff advisor to the commander.  In so doing, the physician
participates in the development of command plans and policies,
advises the commander on relevant medical issues, and works with
other staff officers to ensure medical support of military
operations.  Given these responsibilities, military physicians need
an understanding of military operations, staff planning and
administration processes, the various work environments, and the
natural and manmade hazards that personnel may encounter. 


   OBJECTIVES, SCOPE, AND
   METHODOLOGY
---------------------------------------------------------- Chapter 1:3

Even before its first class enrolled in 1976, the University was
controversial.  Several earlier studies have concluded that the
University is the most costly source of obtaining military
physicians.  Consequently, proposals have been made to close the
University, including one that resulted from the work of the National
Performance Review (NPR).\8

The National Defense Authorization Act for Fiscal Year 1995
specifically prohibited the closure of the University and directed us
to report on issues related to the University and other sources of
military physicians.  The act directed us to report on various
aspects of physician accession programs including costs, retention
rate patterns, quality of medical education, and preparation for the
special needs of military medicine.  The act also directed us to
report on actions taken by the University in response to
recommendations made in 1990 by DOD's Inspector General concerning
internal controls and other issues. 

To respond to these issues, we collected information (through
interviews and documentation) from the following organizations and
officials: 

  the Office of the Assistant Secretary of Defense (Health Affairs);

  the Uniformed Services University of the Health Sciences;

  the Joint Staff;

  the Offices of the Surgeons General of the Army, Navy, and Air
     Force;

  medical readiness training representatives for each service;

  major medical units throughout DOD;

  the Office of Management and Budget;

  NPR;

  the Congressional Budget Office;

  the American Medical Association;

  the Association of American Medical Colleges; and

  various other organizations within and outside of DOD. 

A detailed discussion of our methodology is presented in appendix I. 

The results of our cost analysis are presented in chapter 2.  Chapter
3 discusses the quality of medical education obtained by military
physicians and how physicians from each accession source are prepared
to meet the special needs of military medicine.  Chapter 4 provides
information on the activities conducted at the University in addition
to its School of Medicine.  Chapter 5 provides information on issues
related to the retention of physicians.  Chapter 6 presents overall
conclusions about military physician accession programs and related
issues.  Appendix IV discusses the responses to the 1990
recommendations of DOD's Inspector General. 

Our work was conducted between September 1994 and August 1995 in
accordance with generally accepted government auditing standards. 


--------------------
\8 NPR, led by Vice President Gore, was an Administration effort to
identify opportunities to streamline government operations.  In
September 1993, NPR recommended closing the University. 


ANALYSIS OF UNIVERSITY AND
SCHOLARSHIP PROGRAM COSTS
============================================================ Chapter 2

Our review of the costs of obtaining and retaining physicians for the
military focused on the historical educational costs for the
graduating class of 1994 and the projected postgraduation costs for
additional training (including GME and initial medical readiness
training), salary, and retirement costs.  We analyzed prior studies
and held discussions with military and civilian officials to identify
the factors to include in our analysis.  Our analysis showed that
when considering DOD costs, the University is the most expensive
source of military physicians.  In a supplemental analysis, which
includes an estimate of additional federal support for medical
education, the University is the most expensive on a per graduate
basis but comparable in cost to other accession sources when
physician costs are distributed over the expected lengths of their
military careers. 


   KEY FACTORS CONSIDERED IN OUR
   ANALYSIS
---------------------------------------------------------- Chapter 2:1

In developing our analysis of University and scholarship program
costs, we made decisions regarding the following key factors: 

  the appropriate year to use as the base year for analytical
     purposes,

  the appropriate units of analysis against which to compare the
     estimated costs for each program,

  the use of retention rate data in the cost equations, and

  the appropriate methods of treating various components of each
     program's costs. 

Each factor is discussed below with particular reference to the
differences in approaches used by the Office of the Assistant
Secretary of Defense, Program Analysis and Evaluation (PA&E), and the
University\9 in their analyses of the costs of obtaining physicians
for the military.  The University's study, which responds to the
issues that we were asked to address in the National Defense
Authorization Act for Fiscal Year 1995, concluded that the
scholarship program (as a combined program) is almost 2 times more
costly than the University.  The DOD study concluded that the
University was 20 to 27 percent more costly than the regular
scholarship program and 39 to 63 percent more costly than the
deferred scholarship program, depending on medical specialty. 


--------------------
\9 The University "Working Copy" for the Senate Armed Services
Committee Directed USUHS Review, March 1995, Physician Retention and
the Cost-Effectiveness of the Uniformed Services University of the
Health Sciences, DOD/Office of the Assistant Secretary of Defense
(PA&E), July 1991. 


      BASE YEAR FOR ANALYSIS
-------------------------------------------------------- Chapter 2:1.1

Our review focused on the historical educational costs for the
graduating class of 1994 and the projected costs for additional
training and career compensation as expressed in 1994 constant
dollars.  Our focus on a specific graduating class represents a
snapshot of the cost factors as they existed at the time of our
analysis and can provide a benchmark for later analyses.  The
University's analysis is also based on the 1994 graduating class;
however, the PA&E analysis was performed in 1991 using 1989 data. 


      UNIT OF ANALYSIS
-------------------------------------------------------- Chapter 2:1.2

PA&E used the number of expected years of service for the graduates
of each program as the measure of benefit and the estimated cost per
expected year of service as its unit of analysis.  The University
used the number of years of obligation for the graduates of each
program as the measure of benefit and the cost per year of obligation
as its unit of analysis.\10

We used the PA&E unit of measurement and analysis (expected years of
service)\11 and the costs per graduate from each program as an
interim unit of analysis.  We believe that the University's focus on
the minimum obligation period understates each program's contribution
to military medicine because some graduates from all accession
programs are retained longer than the minimum obligation period,
including some who stay to retirement. 

For example, under the University model, the 155 graduates from its
class of 1994 are expected to provide 1,085 staff years of service
based on a 7-year obligation.  For the scholarship program, the
University model uses a 4-year obligation, which results in 2,816
expected staff years of service for the regular scholarship program
and 1,132 for the deferred scholarship program. 

Table 2.1 shows our calculation of expected years of service for 1994
graduates of the University and the scholarship program using DOD
physician retention projections. 



                               Table 2.1
                
                  Expected Years of Service From Each
                            Accession Source

                                                              Expected
                                                Expected      years of
                                                years of  service from
                              Graduates in   service per          1994
Accession source                      1994      graduate     graduates
----------------------------  ------------  ------------  ------------
USU                                    155         18.45         2,860
HPSP (regular)                         704          9.75         6,865
HPSP (deferred)                        283          5.29         1,497
----------------------------------------------------------------------

--------------------
\10 The scholarship program obligation of 4 years is an estimate
based upon experience, whereas the University obligation of 7 years
is supported by the statute. 

\11 The University developed this measure in 1975 because it expected
its environment would cause a larger percentage of its graduates to
choose the military as a career. 


      RETENTION RATES
-------------------------------------------------------- Chapter 2:1.3

The selection of the expected years of service as our unit of
analysis required that we use physician retention data in our
calculations.  Since 1981, DOD has maintained an electronic database
on the rates at which physicians leave or stay in the military.  The
retention database identifies the program through which physicians
are obtained, the military department, and the percentage of
physicians remaining each year.  DOD makes projections about (1) the
average years of service that may be anticipated from physicians and
(2) the percentage of physicians expected to stay in the military to
retirement from each accession source.  DOD's projections are based
on historical retention data for each program and the experience of
all military physicians. 

DOD officials acknowledged that their retention database has not been
updated since 1993.  However, DOD and service officials agreed that
DOD's projections using this database are the best DOD-wide
information available on the retention of military physicians.  We
used DOD's retention projections to calculate the expected staff
years of service for each accession source by multiplying the actual
number of graduates from each program by the expected years of
service for graduates from each program.  We also calculated
projected career compensation (salary and bonuses) and retirement
costs using the DOD physician retention data. 


      TREATMENT OF PROGRAM COSTS
      AND UNCERTAINTIES
-------------------------------------------------------- Chapter 2:1.4

PA&E examined the costs of procuring and retaining physicians from
medical school through retirement.  PA&E's cost elements included the
University's budget, educational costs for the scholarship program,
military GME costs, salary and bonuses during a physician's career,
and estimates of physician retirement benefits.  The University's
methodology focused on its operational budget and scholarship program
educational costs, but excluded the other DOD costs associated with
training and retaining physicians used in the PA&E model. 

We used the PA&E cost elements when considering DOD's costs.  DOD
incurs costs for military physicians after they graduate from medical
school--including the University--because of medical and military
training requirements and to pay salaries and benefits during the
military physician's career.  Under our calculation, educational
costs represent about 9 percent of DOD's total costs for the regular
scholarship program, about 17 percent for the University, and about
19 percent for the deferred scholarship program. 


      TREATMENT OF SOME UNIVERSITY
      COSTS
-------------------------------------------------------- Chapter 2:1.5

The total University budget in any year includes funding for
activities that do not directly contribute to the education of a
medical student.  For example, in fiscal year 1994, the University
budget included $28.5 million for projects, such as research on head
and neck injuries, and the Armed Forces Radiobiological Research
Institute.  DOD and University officials agreed that these costs
should not be included because they are not associated with the
education of physicians.  However, the University excluded an
additional $18.6 million from its analysis for cost-avoidance
activities.  These are largely faculty and staff activities that the
University believes DOD would continue to procure even if the
University is closed, but at potentially higher costs. 

We have not included the University's reductions for cost avoidance
because our methodology focused on the actual outlays for the
educational costs of the University and the scholarship program. 
Moreover, we were unable to validate the details in the University's
cost avoidance estimates. 


      ADDITIONAL FEDERAL DOLLARS
      TO CIVILIAN MEDICAL
      EDUCATION
-------------------------------------------------------- Chapter 2:1.6

The University included additional federal contributions to civilian
medical education (and by extension to the scholarship program) in
its analysis, while the PA&E study did not.  Considerable debate
exists about whether other (non-DOD) federal support for medical
education should be considered in the cost of obtaining military
physicians.  Authors of previous cost studies have argued that
inclusion of these funds is inappropriate because this funding is
made to civilian schools for reasons totally unrelated to the
scholarship program.  Counterarguments suggest that other federal
support should be attributed to the scholarship program because
civilian medical schools require this federal support to continue
their operations. 

If other federal expenditures for the education of scholarship
program students are included in the analysis, only a portion of
these costs should be viewed as related to their careers as military
physicians.  For example, deferred scholarship program graduates
serve about 5.29 years in the military on average and many more in
the private sector.  Nonetheless, because of the interest in some
quarters for inclusion of other federal costs, we developed a
supplemental analysis including, as a subsidy to the scholarship
program, Department of Health and Human Services funding to civilian
medical schools for research and GME programs (commensurate with the
rate of scholarship program participation in civilian undergraduate
and graduate medical education programs). 

In an effort to ensure comparability between the cost elements in the
programs, we also included other federal dollars to the University in
the form of research grants and support for its graduates who
participated in civilian GME programs. 

Additional details about our cost methodology are in appendix I. 


   RESULTS OF OUR ANALYSIS
---------------------------------------------------------- Chapter 2:2

Our analysis of DOD's costs to educate and retain a military
physician showed that the University is more costly than the
scholarship program on a per graduate and an expected year of service
basis.  To illustrate: 

  DOD's educational costs per graduate were $566,506 for the
     University and $125,946 for the scholarship program;\12

  DOD's educational costs per expected year of service were $30,697
     for the University, $12,916 for the regular scholarship program,
     and $23,825 for the deferred scholarship program;

  DOD's total per graduate costs were $3.3 million for the
     University, $1.5 million for the regular scholarship program,
     and $0.7 million for the deferred scholarship program; and

  DOD's total costs per expected year of service were $176,236 for
     the University, $149,969 for the regular scholarship program,
     and $124,801 for the deferred scholarship program. 

Our supplemental analysis showed that when an estimate of additional
federal dollars that support civilian medical education is included
in the analysis, the University is more costly on a per graduate
basis, but on an expected year of service basis, the University is
nearly equal the cost of the regular scholarship program and less
costly than the deferred scholarship program.  To illustrate: 

  the total cost per graduate, when all federal costs are included,
     was $3.4 million for the University, $1.8 million for the
     regular scholarship program, and $1.2 million for the deferred
     scholarship program; and

  the total cost per expected year of service, when all federal costs
     are included, was $181,575 for the University, $181,169 for the
     regular scholarship program, and $231,501 for the deferred
     scholarship program. 


--------------------
\12 Educational costs are the same on a per graduate basis for the
deferred and regular scholarship programs. 


      DOD EDUCATIONAL COSTS ARE
      HIGHER FOR THE UNIVERSITY
      THAN FOR THE SCHOLARSHIP
      PROGRAM
-------------------------------------------------------- Chapter 2:2.1

The medical educational costs associated with the University include
facility operations and maintenance, research and development,
procurement, construction, and military and PHS salaries for faculty
and students.  Educational costs associated with the scholarship
program include medical school tuition and fees, stipends and
salaries for students, summer training, and program administration. 

The DOD cost to educate the 1994 graduates of the University was
$566,506 per graduate--4-1/2 times as great as the cost to educate a
medical student through the scholarship program ($125,946). 


      UNIVERSITY COSTS ARE
      AMORTIZED OVER A LONGER
      PERIOD OF TIME
-------------------------------------------------------- Chapter 2:2.2

The difference in cost between the University and the scholarship
program narrows when education costs are amortized over the expected
length of service for each group.  DOD estimates show that physicians
from the University are expected to serve nearly twice as long as
their regular scholarship program peers and more than three times as
long as deferred scholarship program physicians.  Using DOD estimates
that, on average, physicians from the University will serve 18.45
years; regular scholarship program physicians 9.75 years; and
deferred scholarship program physicians 5.29 years, our calculation
of the educational cost per expected year of service for University
graduates was $30,697.  Costs per expected year of service for
University graduates are more than twice those for regular
scholarship program participants ($12,916) who begin active military
service immediately after graduation and 29 percent higher than the
per expected year of service cost for scholarship program
participants ($23,825) who defer their military service to attend GME
in civilian institutions.  Table 2.2 compares DOD's educational costs
for University and scholarship program physicians who graduated in
1994 on a per graduate and per expected year of service basis. 



                               Table 2.2
                
                  Educational Costs for University and
                         Scholarship Graduates

                        USU          HPSP (regular)   HPSP (deferred)
----------------  ----------------  ----------------  ----------------
Per graduate          $566,506          $125,946          $125,946
Per year of            30,697            12,916            23,825
 service
----------------------------------------------------------------------

      GME AND MEDICAL READINESS
      TRAINING
-------------------------------------------------------- Chapter 2:2.3

Regular scholarship program participants and most University
graduates receive additional medical training through GME programs
primarily in DOD's medical treatment facilities.  DOD's most current
study of its military GME costs (based on 1992 data) estimated the
annual GME cost per participant at $168,777, including resident
salaries.\13 Assuming an average of 4 years of GME for each
participant, the GME per participant cost is $521,048, after
adjusting for inflation.  (Military GME costs do not apply to
deferred scholarship program or University graduates who participate
in civilian GME programs.) While the GME costs on a per participant
basis are identical for the University and the regular scholarship
program, the per graduate costs differ because the University costs
are spread over all its graduates (155), even though 6 University
graduates participate in civilian GME programs.  GME costs for those
6 University graduates and all deferred scholarship participants are
included in "non-DOD federal dollars", as discussed on page 31. 
Table 2.3 shows our projections of DOD's GME costs for University and
regular scholarship program physicians who graduated in 1994. 



                               Table 2.3
                
                 Projected Costs of GME for University
                       and Scholarship Graduates

                                 USU                HPSP (regular)
----------------------  ----------------------  ----------------------
Per graduate                   $500,879                $521,048
Per year of service             27,141                  53,433
----------------------------------------------------------------------
In addition to their graduate medical education, military physicians
are required to have basic officer training, regardless of their
accession source.  In general, new scholarship program physicians
also attend the Combat Casualty Care Course to acquire basic field
medical skills.  (University graduates generally do not attend the
Combat Casualty Care Course.) Our projected costs (based on DOD
estimates) of these training courses for the physicians who graduated
in 1994 are shown in table 2.4. 



                               Table 2.4
                
                     Costs of Military Training for
                  University and Scholarship Graduates

                        USU          HPSP (regular)   HPSP (deferred)
----------------  ----------------  ----------------  ----------------
Per graduate           $5,776           $10,970           $10,970
Per year of             313              1,125             2,075
 service
----------------------------------------------------------------------

--------------------
\13 Cost Analysis of the Military Medical Care System Institute for
Defense Analysis, September 1994. 


   CAREER COMPENSATION IS HIGHER
   FOR UNIVERSITY GRADUATES THAN
   FOR SCHOLARSHIP PARTICIPANTS
---------------------------------------------------------- Chapter 2:3

In addition to the cost of medical education, DOD bears physician
retention costs, including career salary and bonuses, as well as
retirement benefits.  Compensation costs are estimated to be highest
for graduates of the University because, on average, they are
expected to remain in the service longer and to earn retirement
benefits at a rate higher than either their deferred or regular
scholarship program peers. 


      SALARY AND BONUSES ARE
      HIGHEST FOR UNIVERSITY
      GRADUATES
-------------------------------------------------------- Chapter 2:3.1

Active duty compensation for physicians includes regular pay and
allowances as well as special pay and bonuses that vary depending
upon board certification status, length of service, and other
factors.  Because University graduates will be compensated over a
greater number of years than their scholarship program peers, the per
graduate compensation costs are estimated to be the highest for
University graduates.  Deferred scholarship program graduates earn
nearly as much on an expected year of service basis because they
enter active duty service after becoming fully trained in a medical
specialty and, thus, receive higher compensation for the fewer years
they serve.  University and regular scholarship program graduates
receive lower salaries while in military GME programs than they earn
after their GME training, which reduces their average career earnings
on an expected year of service basis.  Table 2.5 shows the estimated
costs of salary and bonuses for the University and scholarship
program physicians who graduated in 1994. 



                               Table 2.5
                
                    Costs of Salary and Bonuses for
                  University and Scholarship Graduates

                        USU          HPSP (regular)   HPSP (deferred)
----------------  ----------------  ----------------  ----------------
Per graduate         $1,739,626         $723,257          $497,302
Per year of            94,265            74,169            94,075
 service
----------------------------------------------------------------------

      RETIREMENT COSTS ARE HIGHER
      FOR UNIVERSITY GRADUATES
      THAN FOR SCHOLARSHIP
      PARTICIPANTS
-------------------------------------------------------- Chapter 2:3.2

Military physicians are eligible for retirement benefits after 20
years of active military service.  Because the University graduated
its first class only 15 years ago, actual retirement data are not
available.  However, based on experience with other military
physicians, DOD estimates that about 50 percent of the 1994
University graduates will remain on active duty through retirement,
compared with 3 percent for deferred scholarship program graduates
and 11 percent for regular graduates.  Because the expected
retirement rate for University graduates is higher than their
scholarship program peers, projected retirement costs for physicians
who graduated in 1994 are correspondingly higher for the University,
as shown in table 2.6. 



                               Table 2.6
                
                 Retirement Benefits for University and
                        Scholarship Graduates\a

                        USU          HPSP (regular)   HPSP (deferred)
----------------  ----------------  ----------------  ----------------
Per graduate          $439,575          $81,186            25,506
Per year of            23,819            8,326             4,825
 service
----------------------------------------------------------------------
\a Retirement benefits do not include DOD contributions to Social
Security or other retirement plans. 

Table 2.7 summarizes DOD costs for educating and retaining military
physicians. 



                                    Table 2.7
                     
                        DOD Costs for Education and Career
                          Compensation of University and
                              Scholarship Graduates


                                            HPSP    HPSP            HPSP    HPSP
                                        (regular  (defer          (regul  (defer
Cost element                       USU         )    red)     USU     ar)    red)
----------------------------  --------  --------  ------  ------  ------  ------
Education                     $566,506  $125,946  $125,9  $30,69  $12,91  $23,82
                                                      46       7       6       5
Pay                           1,739,62   723,257  497,30  94,265  74,169  94,075
                                     6                 2
Retirement                     439,575    81,186  25,506  23,819   8,326   4,825
GME                            500,879   521,048      \a  27,141  53,433      \a
Military                         5,776    10,970  10,970     313   1,125   2,075
 training
================================================================================
Total DOD costs\b             $3,252,3  $1,462,4  $659,7  $176,2  $149,9  $124,8
                                    62        08      24      36      69      01
--------------------------------------------------------------------------------
\a Not applicable; deferred scholarship students do not participate
in military GME programs. 

\b Totals may not add due to rounding. 


   NON-DOD FEDERAL DOLLARS FOR
   MEDICAL EDUCATION AND GME
   INCREASE OVERALL COSTS
---------------------------------------------------------- Chapter 2:4

Beyond the costs to DOD, a portion of the federal dollars that
support undergraduate and graduate medical education may be
considered as part of the overall cost of educating military
physicians.  For example, one form of federal support for
undergraduate medical education is research funding through the
National Institutes of Health ($5.7 billion in 1994) and other
federal agencies.  Similarly, a portion of the federal dollars that
support civilian GME through the Medicare program ($6.2 billion in
1994) may be considered relevant to the overall cost of educating
physicians from the deferred scholarship program and the University
(six Public Health Service graduates from the University's class of
1994 are participating in civilian GME programs).  Table 2.8 shows
our estimate of these costs. 



                               Table 2.8
                
                Federal Support Allocable to University
                       and Scholarship Graduates

                        USU          HPSP (regular)   HPSP (deferred)
----------------  ----------------  ----------------  ----------------
Per graduate          $98,522           $304,248         $564,038\a
Per year of            5,339             31,200           106,700
 service
----------------------------------------------------------------------
\a The deferred scholarship program includes federal support for
undergraduate ($304,248) and graduate medical education ($259,790). 

When all federal costs are included on a per graduate basis, our
analysis shows that at a cost of $3.4 million, the University is
about 1.9 times more expensive than the regular scholarship program
($1.8 million) and more than 2.7 times more expensive than the
deferred scholarship program ($1.2 million).  However, when total
federal costs are spread over the expected life of a physician's
military career, the University is more comparable in cost to the
other accession sources at $181,575 per expected year of service. 
The deferred scholarship program is the most expensive source using
this approach at $231,501, while total federal costs for the regular
scholarship program total $181,169 on an expected years of service
basis.  Table 2.9 summarizes total federal costs for obtaining and
retaining military physicians. 



                                    Table 2.9
                     
                      Total Federal Costs for Education and
                      Career Compensation of University and
                              Scholarship Graduates


                                                                  HPSP      HPSP
                                  HPSP        HPSP            (regular  (deferre
                       USU   (regular)  (deferred)       USU         )        d)
--------------  ----------  ----------  ----------  --------  --------  --------
Education         $566,506    $125,946    $125,946   $30,697   $12,916   $23,825
Pay              1,739,626     723,257     497,302    94,265    74,169    94,075
Retirement         439,575      81,186      25,506    23,819     8,326     4,825
GME                500,879     521,048          \a    27,141    53,433        \a
Military             5,776      10,970      10,970       313     1,125     2,075
 training
Total DOD       $3,252,362  $1,462,408    $659,724  $176,236  $149,969  $124,801
 costs\b
Other federal      $98,522    $304,248  $564,038\c    $5,339   $31,200  $106,700
 support
Total federal   $3,350,883  $1,766,656  $1,223,762  $181,575  $181,169  $231,501
 costs\b
--------------------------------------------------------------------------------
\a Not applicable.  GME costs for deferred scholarship program
participants are included in other federal support. 

\b Totals may not add due to rounding. 

\c The deferred scholarship program includes federal support for
undergraduate ($304,248) and graduate medical education ($259,790). 


THE UNIVERSITY PROVIDES MEDICAL
EDUCATION COMPARABLE TO CIVILIAN
SCHOOLS AND EMPHASIZES THE SPECIAL
NEEDS OF MILITARY MEDICINE
============================================================ Chapter 3

Our analysis shows that the University's School of Medicine provides
a traditional medical education that compares well with other U.S. 
medical schools and combines that education with coverage of topics
more specifically related to the practice of military medicine. 
Traditional measures of quality place the University's program within
the midrange of medical schools nationwide and its graduates at or
above other military physicians.  The commanders of military medical
treatment facilities that we contacted regard physicians who are
graduates of the University as at least as well-prepared as their
civilian-educated colleagues for the practice of medicine in the
clinical setting.  Our analysis shows that the University also
provides students more exposure to the special needs of military
medicine.  Also, the medical commanders believe that the University's
approach produces physicians who at least initially are better
prepared than their civilian-educated peers to meet the demands of
military medicine.  However, no conclusive evidence exists to show
that University graduates are better prepared to meet DOD's
operational needs. 


   QUALITY OF MEDICAL EDUCATION AT
   THE UNIVERSITY COMPARES
   FAVORABLY WITH THAT PROVIDED BY
   OTHER SOURCES
---------------------------------------------------------- Chapter 3:1

Indicators generally accepted in the medical community show that the
University provides the military services with physicians whose
medical education is equivalent in quality to the education received
by other military physicians.  The University's School of Medicine is
fully accredited and its students have undergraduate grade point
averages and admission test scores that fall within the midranges for
such statistics for all medical schools.  Postgraduate measures such
as pass rates for the medical license examination and graduates'
performance in their first year of GME indicate that University
graduates are equivalent to or slightly better than other military
physicians. 


      THE UNIVERSITY HAS EARNED
      FULL ACCREDITATION
-------------------------------------------------------- Chapter 3:1.1

Most medical schools in the United States are accredited by the
Liaison Committee on Medical Education (LCME), a joint activity of
the Association of American Medical Colleges (AAMC) and the Council
on Medical Education of the American Medical Association.\14 In April
1993, LCME awarded the University full accreditation for 7 years, the
standard length of time.  LCME also identified areas for improvement
during the accreditation process, including an overly dense
curriculum\15 (particularly for students' first 2 years) and
vacancies in several department chairs. 

In February, 1995, LCME notified the University of its satisfaction
with the University's progress in making improvements in these areas. 
For example, in response to the concerns raised about the density of
its curriculum, modifications were made to the curriculum of the
basic sciences to allow an afternoon of self-study in most weeks for
first and second year students.  In addition, four of the five vacant
faculty chairs were filled.  However, in June 1995, the position of
the Dean of the School of Medicine became vacant and, as of September
1995, the School was seeking a permanent Dean. 

In addition to LCME's accreditation of the School of Medicine, the
University, as a whole, has been accredited by the Commission on
Higher Education of the Middle States Association of Colleges and
Schools, an organization that accredits institutions of higher
learning. 


--------------------
\14 LCME accredits the University's School of Medicine and the other
125 allopathic medical schools in the United States.  U.S.  schools
of osteopathic medicine are accredited by the American Osteopathic
Association. 

\15 A curriculum that includes a very high percentage of classroom
instruction, leaving little time for independent study. 


      CHARACTERISTICS OF STUDENTS
      ENTERING THE UNIVERSITY
-------------------------------------------------------- Chapter 3:1.2

In the medical community, the academic credentials of the students
that a medical school attracts are considered to be a reflection of
the school's quality.  Two widely used measures of academic
achievement among medical school applicants are undergraduate grade
point averages (GPA) and scores on the Medical College Admissions
Test (MCAT). 

Compared with their peers nationwide, students who entered the
University in the fall of 1994 had above average MCAT scores.  In
addition, the MCAT scores of students at the University were higher
than those for the Army and Navy scholarship program participants who
entered in 1994.  Figure 3.1 shows these averages. 

   Figure 3.1:  MCAT Scores for
   University and Other Students
   Entering Medical School in 1994

   (See figure in printed
   edition.)

Note:  GPA is computed on a 4-point scale.  The Air Force was not
able to provide similar data. 

In contrast, Figure 3.2 shows that University students had average
undergraduate GPAs that were slightly below the national average,
higher than Army scholarship program entrants, and equivalent to Navy
scholarship program entrants. 

   Figure 3.2:  Undergraduate GPAs
   for University and Other
   Students Entering Medical
   School in 1994

   (See figure in printed
   edition.)

Note:  MCAT is graded on a 15-point scale.  The Air Force was not
able to provide similar data. 


      ACHIEVEMENTS OF UNIVERSITY
      GRADUATES
-------------------------------------------------------- Chapter 3:1.3

University graduates compare favorably with other medical school
graduates in their performance on the United States Medical Licensing
Examination (USMLE) and in their evaluations from internships at
military medical treatment facilities.  Military medical commanders
believe that University graduates perform as well or better
clinically than other military physicians.  DOD data indicate that
University graduates are cited for fewer adverse clinical privileging
actions than other military physicians. 


      UNIVERSITY STUDENTS PERFORM
      WELL ON USMLE
-------------------------------------------------------- Chapter 3:1.4

All students seeking medical licensure take the three steps of the
USMLE, administered by the National Board of Medical Examiners.  Part
1 tests the student's ability to apply knowledge of the basic
biomedical sciences, part 2 assesses the student's application of
clinical capabilities under supervision, and part 3 measures the
candidate's use of medical knowledge deemed appropriate for the
unsupervised practice of general medicine.  The most recent
University class to have completed all three parts of the USMLE is
the class that graduated in 1993.  Those students took parts 1 and 2
while at the University and part 3 during their internship, scoring
near the national average for all medical students and achieving pass
rates that were equal to or better than the pass rates for all
medical students, as shown in table 3.1. 



                               Table 3.1
                
                     Results of USMLE Taken by the
                   University's 1993 Graduating Class

                                                Part 1  Part 2  Part 3
----------------------------------------------  ------  ------  ------
USU average                                      199\a   195\b   497\c
National average\d                                 200     200     480
USU pass rate                                      92%     94%     97%
National pass rate                                 88%     94%     96%
----------------------------------------------------------------------
\a Scores are reported on an open-ended scale, with the mean usually
about 200; passing score was 176. 

\b Scores are reported on an open-ended scale, with the mean usually
about 200; passing score was 167. 

\c Scores are reported on an open-ended scale, with the mean usually
about 500; passing score was 310. 

\d Includes graduates of Canadian medical schools. 

The classes that graduated in 1994 and 1995 had completed only parts
1 and 2 of the examination at the time of our review.  The results of
those tests are shown in table 3.2. 



                               Table 3.2
                
                     Results of USMLE Taken by the
                 University's 1994 and 1995 Graduating
                                Classes


                                        Part 1  Part 2  Part 1  Part 2
--------------------------------------  ------  ------  ------  ------
USU average                                201     197     203     198
National average                           200     200     203     198
USU pass rate                              96%     95%     97%     96%
National pass rate                         89%     93%     91%     92%
----------------------------------------------------------------------

      UNIVERSITY GRADUATES PERFORM
      WELL DURING INTERNSHIP
-------------------------------------------------------- Chapter 3:1.5

The three military services operate GME programs.  During the
internship (the first year of GME), physicians are evaluated 13
times.  We reviewed the evaluations for all interns at the Air
Force's Malcolm Grow Medical Center, the Walter Reed Army Medical
Center, and the Bethesda National Naval Medical Center for the
academic year 1993-94.\16 On average, for the sample we reviewed,
interns who graduated from the University received similar or higher
evaluations than interns who graduated from other medical schools, as
shown in table 3.3. 



                               Table 3.3
                
                      Intern Evaluations for 1994

                                                   Air
                                                 Force    Army    Navy
----------------------------------------------  ------  ------  ------
Average evaluation for USU graduates\a            5.63   87.53    3.86
                                                (15)\b     (9)    (25)
Average evaluation for other interns              5.26   86.02    3.81
                                                   (6)    (49)    (37)
----------------------------------------------------------------------
\a Air Force interns were evaluated on a 7-point scale, the Army
interns on a 100-point scale, and the Navy interns on a 4-point
scale. 

\b The number of interns evaluated is in parentheses. 


--------------------
\16 These programs, all in the Washington, D.C., area, represent only
a small portion of the military's internship programs.  We cannot
project the results of our analysis to other military internship
programs or to other years of the three programs in our analysis. 


      MILITARY MEDICAL COMMANDERS
      VIEW UNIVERSITY GRADUATES
      AND OTHER MILITARY
      PHYSICIANS AS COMPARABLE
      CLINICIANS
-------------------------------------------------------- Chapter 3:1.6

We contacted 24 commanders of the largest military hospitals, most of
whom believe that University graduates equal their civilian-educated
colleagues in terms of overall clinical capabilities.  Typical was
the remark made by the commander of an Army hospital: 

     "The graduates of [the University] demonstrate the same spectrum
     of abilities and clinical aptitude as the graduates from any of
     our best civilian medical institutions.  I have seen no
     difference in intellect or performance."

Others noted less variation in the quality of University graduates. 
For example, the commander of an Army medical center said

     "The [University] graduates are of a more consistent level of
     quality [compared with] a spectrum of abilities that come from
     the variety of civilian medical school sources."


      ADVERSE ACTIONS AMONG
      UNIVERSITY GRADUATES ARE FEW
-------------------------------------------------------- Chapter 3:1.7

DOD tracks adverse clinical privileging actions as an indicator of
the performance of military physicians.  Adverse clinical privileging
actions can involve a range of activities such as malpractice, drug
abuse, or unprofessional conduct.  Based upon our analysis of data
maintained by the Armed Forces Institute of Pathology, physicians who
graduated from the University have had fewer reported adverse
clinical privileging actions than military physicians from other
sources.  From 1982 to 1994, University graduates had 19 reported
actions, or 1.48 actions per 1,000 physician staff years.  During
that same period, physicians from the scholarship program had 234
actions, or 3.06 actions per 1,000 physician staff years. 


   UNIVERSITY STUDENTS RECEIVE
   EXTENSIVE MEDICAL READINESS
   TRAINING, BUT ITS IMPACT IS
   UNCLEAR
---------------------------------------------------------- Chapter 3:2

Preparing physicians for the special needs of military medicine
involves education, training, and experience beyond that of a
traditional medical education.  This additional preparation is
broadly referred to as medical readiness training.\17 Our analysis
shows that the medical readiness training provided to University
medical students is more extensive than that initially given to other
military physicians in terms of the amount of time involved and the
nature of the training.  Leaders in military medicine that we
contacted consider University graduates to be better prepared for
military medicine, at least during the early years of their careers. 
However, University and DOD officials do not know of any objective
evidence that shows that the extensive readiness training at the
University produces physicians who are better prepared than their
peers to meet the special needs of military medicine. 


--------------------
\17 As used in this report, medical readiness training refers to any
education or training (including basic officer training) designed to
enhance the knowledge and skills of health care personnel in concepts
of military medicine. 


      READINESS TRAINING AT THE
      UNIVERSITY IS MORE EXTENSIVE
      THAN THAT GIVEN TO OTHER NEW
      PHYSICIANS
-------------------------------------------------------- Chapter 3:2.1

Military physicians currently receive their initial readiness
training through one of two means:  University medical school
students receive medical readiness training as part of their 4-year
medical education; graduates of civilian medical schools receive it
by attending medical readiness training courses that the services
offer individually or jointly.  The medical readiness training given
to University medical students is more extensive in volume and
breadth than the initial medical readiness training for other
physicians. 


      UNIVERSITY STUDENTS RECEIVE
      MORE HOURS OF INITIAL
      READINESS TRAINING THAN
      OTHER NEW MILITARY
      PHYSICIANS
-------------------------------------------------------- Chapter 3:2.2

According to University officials, the University's curriculum is
intended to provide the medical and military knowledge and
capabilities that the curriculum developers felt was necessary to
prepare a physician to function in a leadership role in a range of
operational assignments and environments.  At our request, University
officials identified the hours of its curriculum devoted to medical
readiness topics.  According to those officials, University medical
students receive an estimated 734 hours of readiness training
(including both classroom and field exercises).  They also receive at
least 50 hours of medical readiness training during the officer basic
training that they are required to attend before beginning their
first year at the University.\18 Thus, by the time they graduate,
University medical students have received between 784 and 889 hours
of readiness training, depending upon the service branch involved. 

Service training officials and guidance indicate that the objectives
of the initial readiness training usually provided to other military
physicians are to teach physicians the fundamentals of military
officership and the basic skills needed to treat combat casualties on
the forward points of the battlefield.  New military physicians who
are graduates of civilian medical schools typically receive less
initial readiness training than that provided to University students. 
For example, Air Force physicians who attend only the required basic
officer training receive 50 hours of readiness training.  If they
were to also attend the optional Combat Casualty Care Course (C4),
the total number of hours would increase to about 132 hours.\19
Figure 3.3 compares the total number of hours of initial readiness
training depending upon the source or sources through which the
training was acquired. 

   Figure 3.3:  Comparison of
   Initial Readiness Training by
   Training Source

   (See figure in printed
   edition.)


--------------------
\18 Some University students, such as those with prior commissioned
service, may not be required to attend basic officer training. 

\19 Regardless of the source of their initial readiness training, all
military physicians can take additional readiness training courses to
sustain and enhance their knowledge and skills.  In the past,
however, physicians have not always attended even required readiness
training. 


      SOME READINESS TOPICS
      COVERED AT THE UNIVERSITY
      ARE NOT COVERED BY INITIAL
      READINESS TRAINING FOR OTHER
      NEW PHYSICIANS
-------------------------------------------------------- Chapter 3:2.3

The portions of the University's curriculum related to military
medicine cover 17 broad areas, some of which are primarily medical in
nature, some of which are primarily military.  With less total time
spent on initial readiness training, the amount of time spent on any
individual topic generally is less for other physicians than for
students at the University.  However, some of the topics that the
University program covers receive no coverage in the initial training
given to other physicians (either in basic officer training or C4.)
For example, the two areas that receive the most coverage in the
military portion of the University's curriculum are tropical medicine
(66 classroom hours) and weapons effects (59 classroom hours.)
Tropical medicine is not covered by the initial readiness training
for other physicians in any service.  Air Force physicians receive 30
minutes of coverage on weapons effects as part of their initial
training; Army and Navy physicians receive none.  Appendix II
compares the hours of training provided by each source. 

University and other DOD officials view the difference between the
University's program and the medical readiness training provided to
other military physicians to be more than a matter of extent and
content.  These officials point out that the information the
University provides concerning military medicine is interwoven
throughout all of its classes, including the basic sciences--not
merely in the classes dedicated to military medicine.  They view the
University's program as fundamentally different from readiness
training in that it is a complete program of education. 


      COMMANDERS VIEW UNIVERSITY
      GRADUATES AS BETTER PREPARED
      FOR MILITARY MEDICINE
-------------------------------------------------------- Chapter 3:2.4

We obtained the perspectives of 44 commanders of major military
medical units about the relative capabilities of University graduates
and their civilian-educated peers.  The responses received were
narrative in nature and did not lend themselves to tabulation. 
However, the overall tenor of the comments was favorable to the
University, even though most of the respondents were graduates of
other accession programs.\20

According to nearly all the medical commanders that we contacted,
University graduates are at least initially better prepared for
military medicine when compared with their peers.  Only one commander
viewed University graduates as no better prepared than their peers
for the practice of military medicine.  The remainder perceived,
among other things, that physicians from the University have a
greater overall understanding of the military, greater commitment to
the military, better preparation for operational assignments, and
better preparation for leadership roles.  Some commanders noted that
the advantage of the University medical education diminishes over
time.  Others expressed the view that the University and civilian
medical schools should be regarded as complementary accession
sources. 


--------------------
\20 Respondents were asked to describe their military experience and
background.  Some respondents identified their accession source in
their written comments. 


      COMMANDERS BELIEVE
      UNIVERSITY GRADUATES HAVE A
      GREATER UNDERSTANDING OF THE
      MILITARY AND THEIR ROLE IN
      IT
-------------------------------------------------------- Chapter 3:2.5

Many of the medical commanders believe that, compared with other
military physicians, University graduates have a better understanding
of the military mission, organization, and customs.  They also said
that they perceive that University graduates have a better
appreciation of and greater satisfaction with the physician's role
within the military.  Others remarked that because of their greater
overall knowledge about the military, University graduates are more
easily assimilated into it.  Some noted that this better
understanding of the military mission and related matters gives
University graduates greater credibility with the nonmedical
personnel whose needs they serve.  Commanders said that they view
University graduates as more committed to the military and to a
military career.  This commitment was sometimes attributed to the
longer pay-back requirement associated with the University.  Typical
of such observations is the following from the commander of an Army
deployable medical unit: 

     "[The University] produces physicians that are not only
     technically competent, but are also able to quickly function as
     .  .  .  military officer[s].  They are already familiar with
     the military corporate culture, which enhances their credibility
     and allows them to progress more rapidly into leadership
     positions.  Civilian graduates are less equipped to do so and,
     in many cases, have no interest in doing so."

Further, the commanders generally stated that they value the
University graduates, as a group, because they view them as a cadre
that provides a source of stability and continuity in military
medicine.  University graduates were generally perceived as
possessing more of the technical knowledge and skills needed in
operational assignments.  The commander of an Army deployable medical
unit remarked that

     "[University] graduates.  .  .  seem to adjust better to field
     conditions when deployed for operations or exercises.  Having
     had some experiences with field medicine during their training,
     they know what to expect when they are called to a battalion aid
     station to provide support.  The civilian school physician is
     often shocked by .  .  .  [the] first encounter with field
     medicine in terms of the austerity and the age of the equipment
     and pharmaceuticals he is expected to use.  In a combat or
     [other operational] scenario, that initial shock can be
     disastrous for the patients unless the physician adjusts quickly
     and learns to make do with what is at hand."


      COMMANDERS PERCEIVE
      UNIVERSITY GRADUATES TO BE
      BETTER PREPARED TO ASSUME
      LEADERSHIP ROLES
-------------------------------------------------------- Chapter 3:2.6

The commanders generally viewed University graduates as better
prepared than their peers for leadership roles.  They also saw them
as better team players.  In their roles as leaders and team players,
commanders noted the willingness of University graduates to share
their knowledge in military medicine with their peers.  Because the
University graduates are willing to share their knowledge, the
commanders said that their presence enhances overall readiness among
civilian-educated physicians and other health care providers.  Some
commented on the importance of the acculturation process, which they
believe occurs during the 4 years of medical education at the
University.  Several commanders expressed the view that the
advantages of a medical education from the University would diminish
over time as the civilian-educated physicians acquired additional
training and experience.  The commander of an Army deployable medical
unit commented that

     "[University graduates] generally seem better prepared for field
     duty during the first few years of service.  .  .  . 
     [University] students are taught military bearing and know how
     to act around soldiers.  As time passes, the advantages of being
     schooled in a military environment become less apparent and do
     not appear to play a role after the two or three years that
     civilian graduates take to become accustomed to their Service
     requirements."

Finally, several respondents said that the University and scholarship
programs should not be viewed as competing; rather, they viewed them
as both necessary and complementary.  As expressed by the command
surgeon of a unified command: 

     "[The University] is necessary to provide a corps of physicians
     who have the knowledge base and experience to practice medicine
     in a military environment.  This will provide a substantial
     amount of tomorrow's leaders.  But I don't want to
     underemphasize the importance of the civilian-trained
     physicians.  They bring in a wealth of diverse training that
     ensures the services will have personnel experienced in the
     latest procedures and techniques of civilian medicine."


      OBJECTIVE INFORMATION IS
      LACKING ABOUT THE
      EFFECTIVENESS OF THE
      UNIVERSITY AND OTHER
      READINESS TRAINING
-------------------------------------------------------- Chapter 3:2.7

Objective evidence is lacking concerning the relative effectiveness
of the University and traditional readiness training programs. 
Neither University officials nor others we contacted within DOD were
aware of any specific studies done for the purpose of comparing the
effectiveness of the two approaches for providing readiness training. 
They were also not aware of databases that track information that
would permit such an analysis. 

University officials said that they do not have a formal process in
place to assure themselves that the military portions of their
curriculum are appropriate to meet the needs of their customers. 
They do not seek an official endorsement of their curriculum by the
services or DOD (although the Board of Regents includes the Surgeons
General and a representative from the Office of the Assistant
Secretary of Defense, Health Affairs.) The validity of other medical
readiness training is uncertain as well.  For example, the Chief of
the Joint Medical Readiness Training Center (which administers C4)
said that C4 has remained essentially unchanged since its start in
1980. 

The ultimate measure of a physician's medical readiness is
performance in an actual military deployment.  We and others have
reported that physicians were not adequately qualified for immediate
deployment to Operation Desert Shield/Desert Storm because they
lacked the required readiness training.\21 For those physicians who
were deployed, readiness skills were not comprehensively tested
because the military suffered few casualties.  Likewise, other recent
deployments have not fully tested physician readiness capabilities to
the extent that could be expected in a major conflict.  In peacetime,
the services have not routinely assessed the readiness capabilities
of their physicians.  Thus, neither recent actual deployments nor
peacetime simulations have provided a basis to compare the
performance of University graduates with their civilian-educated
peers. 

DOD and the services lack agreement concerning the medical readiness
knowledge and capabilities that physicians need.  The services offer
training courses to enhance and sustain the medical readiness
capabilities of physicians; however, only one course--officer basic
training--is explicitly required for all military physicians. 
Without agreed upon standards, the validity and effectiveness of
University and other readiness training programs cannot be readily
assessed.  While University graduates have more readiness training
than their contemporaries, the value of that training to DOD and the
services cannot be objectively assessed from a requirements
standpoint. 

In March 1995, DOD recognized the need for improvements in medical
readiness training and set out to develop and establish medical
readiness requirements and standards.\22 Only against such standards
can the validity of the current program at the University and of the
training provided by the services be fully assessed. 


--------------------
\21 Operation Desert Storm:  Full Army Medical Capability Not
Achieved (GAO/NSIAD-92-175, Aug.  18, 1992); Operation Desert Storm: 
Problems with Air Force Medical Readiness (GAO/NSIAD-94-58, Dec.  30,
1993); and Operation Desert Storm:  Improvements Required in the
Navy's Wartime Medical Care Program (GAO/NSIAD-93-189, July 28,
1993). 

\22 Medical Readiness Strategic Plan 1995-2001, Office of the
Assistant Secretary of Defense, Health Affairs (Washington, D.C.: 
1995).  DOD has a draft instruction that is intended to set standards
regarding military medical readiness skills training. 


OTHER ACTIVITIES OF THE UNIVERSITY
============================================================ Chapter 4

To help meet LCME standards required for accreditation as an academic
institution, the University engages in several activities in addition
to operating its School of Medicine.  These fall generally into two
major categories:  (1) education and training activities and (2)
research, consultation, and archival activities.  Financial support
for these activities, mostly the salaries and benefits of the
University's faculty and staff, is provided through the University's
general budget process.  Although these are included in our
computation of the cost to educate University medical students, we
did not evaluate these activities in detail. 

In response to advances in science and medicine, medical schools have
assumed responsibility for or participated in other programs in
medicine and related fields that complement their programs leading to
the Medical Doctor degree.  LCME believes that the education of
medical students is best conducted in such enriched environments. 
Our review of University documents and discussions with University
officials showed that the University conducts several activities that
correspond to LCME standards. 

Currently, the University is the only military organization
conducting some of these functions, such as providing overseas
physicians with required continuing medical education and maintaining
a database on casualty wound treatment cases.  University officials
stated that if the University was not performing these roles, DOD
would need to identify other providers. 


   EDUCATION AND TRAINING
   ACTIVITIES
---------------------------------------------------------- Chapter 4:1

The University provides medical education beyond that provided by the
School of Medicine and also conducts training and education for other
health care and related professions.  This mission is consistent with
the LCME standards that medical schools should include programs for
postdoctoral fellowships, graduate education in the basic medical
sciences, continuing education for physicians, and education in other
health professions and allied fields. 


      OFFICE OF CONTINUING HEALTH
      PROFESSIONAL EDUCATION
-------------------------------------------------------- Chapter 4:1.1

Health professionals, particularly physicians, must acquire certain
levels of continuing education to maintain their licenses.  In fiscal
year 1994, according to a University report to the Office of the
Secretary of Defense, the University's Office of Continuing Health
Professional Education conducted about 600 continuing educational
programs, attended by about 11,000 individuals, mostly military
physicians.  The largest programs are provided for physicians in
Europe, East Asia, and the Pacific, thereby avoiding the costs of
these physicians traveling to U.S.  facilities for training. 
Examples of the courses provided include video endoscopy, obstetrics
ultrasound, and laparoscopic cholecystectomy.\23 The University is
also developing the use of videoconferencing and computer networking
to present its training.  The University also provides certification
for those trained in cardiac resuscitation courses. 


--------------------
\23 Endoscopy is the inspection of the inside of a hollow organ or
cavity using an endoscope--a device consisting of a tube and an
optical system.  Laparoscopic cholecystectomy is gall bladder surgery
using endoscopic procedures. 


      GRADUATE MEDICAL EDUCATION
-------------------------------------------------------- Chapter 4:1.2

LCME accreditation standards also encourage medical schools to
provide or be affiliated with institutions that provide programs in
GME.  (As mentioned in chapter 1, GME programs, which are usually 3
to 7 years in duration, provide physicians training in their chosen
specialty.)

The University is the academic affiliate for several military GME
programs, including three in the Washington, D.C., area, providing
faculty development, research, curriculum enhancement, and patient
care.  In addition, the University's Office of Graduate Medical
Education conducts DOD-wide consultation and oversight for 11 GME
programs sponsored or co-sponsored by the University.  DOD plans to
assign the University with other responsibilities to ensure that
military GME programs maintain their standards of quality for a
smaller military force. 


      GRADUATE EDUCATION IN BASIC
      SCIENCES
-------------------------------------------------------- Chapter 4:1.3

In addition to its continuing education offerings, the University
offers master's and Doctor of Philosophy (Ph.  D.) programs in
anatomy, biochemistry, pharmacology, and other sciences.  Between
1977, when the first students were admitted, and 1994, the University
awarded 128 Ph.D.  and 238 master's degrees.  These graduates form a
pool of researchers and potential instructors at the University or
other institutions.  The University also conducts smaller, more
specialized programs, such as a Ph.D.  program in clinical psychology
for selected military officers. 


      GRADUATE SCHOOL OF NURSING
-------------------------------------------------------- Chapter 4:1.4

The 1993 Defense Appropriations Act directed the University to
implement a training program for nurse practitioners.  Currently, the
University operates accredited masters' nurse programs for family
nurse practitioners and for nurse anesthetists.  The students are
military officers who incur 4 additional years of obligated service
for the 2-year course.  The number of students entering the program
are shown in the following table. 



                               Table 4.1
                
                  Number of Graduate Nursing Students
                    Entering in Fiscal Years 1993-96

                                          Family nurse           Nurse
Fiscal year                              practitioners    anesthetists
--------------------------------------  --------------  --------------
1993                                                 3               0
1994                                                12               9
1995                                                12              12
1996 (estimate)                                     12              20
----------------------------------------------------------------------

   RESEARCH, CONSULTATION, AND
   ARCHIVAL ACTIVITIES
---------------------------------------------------------- Chapter 4:2

The University conducts several research and archival activities both
to meet its accreditation requirements and to advance the practice of
military medicine.  The research, consultation, and archival
activities are conducted by faculty and staff in many departments of
the University, including special centers for (1) casualty care
research, (2) traumatic stress studies, and (3) preventive medicine
and public health.  The activities of each of these centers are
summarized below. 

Casualty Care Research Center:  This center researches and
investigates issues related to injury control, casualty care, and
disaster medicine.  The center employs medical and graduate students
and full-time staff to conduct its research, maintain a database of
casualty care cases, and provide consultation to other federal,
state, and local government agencies. 

A key activity of the Casualty Care Research Center is the Counter
Narcotics Tactical Operations Medical Support program--a week-long
course for emergency medical technicians and paramedics who operate
as part of tactical law enforcement teams.  Among other topics, this
course covers medical care while under fire, hostage survival,
effects of ballistic wounds, and evidence preservation.  The staff
also provides consultation to law enforcement agencies. 

Another mission of this center is maintaining the Wound Data and
Munitions Effectiveness Team, which contains information on the
tactical engagement, weapons employed, resulting injuries, and
treatment of approximately 8,000 Vietnam combat casualties.  Its
collection of photographs, X rays, recovered bullets, and other data
is the only one of its kind. 

Center for Traumatic Stress Studies:  This center conducts research,
maintains archives of medical literature, and provides consultation
for psychiatric responses to trauma and disasters.  Staff also
collect on-site data to facilitate longitudinal follow-up on
disasters and traumatic events.  To illustrate, in 1992 a University
psychiatrist traveled to Florida within 48 hours of Hurricane Andrew
to provide emotional assistance to base personnel and evacuees from
Homestead Air Base.  To increase its knowledge in helping future
victims, the University has surveyed participants in military
engagements (such as the Gulf War) and natural disasters (such as
Hurricane Andrew) to identify their emotional problems and how to
help them. 

Centers for Preventive Medicine and Public Health:  These centers
develop databases and analytic methodologies, and prepare curricula
for and evaluate processes and outcomes in clinical practice.  They
serve program managers and policymakers in DOD, other federal
agencies, local governments, and private organizations concerned with
health policies and services.  These centers address topics that
receive little attention in many civilian medical schools but are
critical to the practice of military medicine, such as foreign area
medical studies, landscape epidemiology, and health in extreme
environments. 


DOD'S RETENTION NEEDS ARE UNKNOWN
============================================================ Chapter 5

DOD's need for physicians has changed as a result of the emergence of
smaller regional threats at the end of the Cold War and the overall
downsizing of the military in response to large budget deficits.  Our
review of DOD retention data shows that University graduates have the
longest expected retention among physicians from the various
accession sources.  Because a higher percentage of University
graduates are expected to reach retirement (20 years), they
contribute to DOD's long-term need for physicians and for medical
specialists considered critical for wartime needs.  Scholarship
program graduates, who are the largest source of military physicians,
generally have shorter careers. 

Although DOD is reevaluating its future need for physicians, it has
not reached conclusions about the number of physicians needed or the
optimal length of time that physicians should serve.  While the
longer pay-back obligation of University graduates is a key factor in
their retention, factors such as age, marital status, compensation,
nonphysician duties, and working conditions have also been associated
with physician retention.  If DOD continues to need a cadre of
experienced career physicians, alternative strategies such as an
enriched scholarship component could be considered as a potentially
more cost effective way to meet DOD's long-term need for physicians. 


   UNIVERSITY AND SCHOLARSHIP
   PROGRAM RETENTION PATTERNS
---------------------------------------------------------- Chapter 5:1

In 1972, when the University and the scholarship program were
authorized, the University was expected to supply DOD's long-term
needs for military physicians, while the scholarship program would
supply the majority of physicians for short-term needs.  Early
graduates of both accession programs are still several years from
retirement eligibility.  Our efforts to determine whether graduates
of both programs had satisfied their pay-back obligations were
hampered by incomplete information on other service commitments
created by factors such as prior service, academy attendance, or
extended GME training.  We reviewed DOD's retention databases to
obtain estimates of the expected retention patterns for University
graduates and scholarship program physicians.  These databases
incorporate information from retention experiences to date for
University and scholarship program physicians and projections of
their future retention based on historical experiences of physicians
from other accession programs. 


      RETENTION RATES FOR
      SCHOLARSHIP PROGRAM
      PHYSICIANS
-------------------------------------------------------- Chapter 5:1.1

DOD has offered scholarships since 1973, but few scholarship program
graduates have served for 20 years to qualify for retirement.  Our
review of DOD retention data shows that regular scholarship program
graduates on average are expected to provide 9.8 years of service,
while deferred scholarship program graduates serve 5.3 years on
average.  Further, using DOD retention data, we project that 11
percent of the regular scholarship program and 3 percent of deferred
scholarship program physicians from the class of 1994 will reach
retirement. 


      RETENTION RATES FOR
      UNIVERSITY GRADUATES
-------------------------------------------------------- Chapter 5:1.2

DOD's retention experience with University graduates is also limited
because the first class graduated in 1980.  As a result, the most
senior alumni have only 15 years of service.\24 The DOD retention
databases show University graduates are expected to provide about
18.5 years of service, and about 50 percent of University graduates
are expected to stay on active duty service for 20 years or longer. 
The longer expected retention of University graduates is consistent
with the legislative intent of providing long-term military medical
officers.  In addition, our analysis of DOD retention data shows that
University graduates are retained at a higher rate in the medical
specialties considered critical for the wartime mission. 


--------------------
\24 Data maintained by the University show that 81 percent of its
physicians who graduated between 1980 and 1985 have remained on
active duty. 


      UNIVERSITY GRADUATES WILL
      LIKELY COMPRISE LARGE
      PORTION OF PEACETIME MEDICAL
      CADRE
-------------------------------------------------------- Chapter 5:1.3

University graduates are expected to comprise a significant portion
of the medical cadre needed for long-term leadership.  For example,
although University graduates were about 14 percent of the physicians
who graduated in fiscal year 1994 (the remaining 86 percent being
scholarship program participants), they are expected to comprise 47
percent of the members from this class who stay 20 years or longer. 


      UNIVERSITY GRADUATES HAVE
      GREATER RETENTION IN THE
      CRITICAL MEDICAL SPECIALTIES
-------------------------------------------------------- Chapter 5:1.4

University graduates also have greater retention in those medical
specialties considered critical for war.  Current readiness planning
considers the medical specialties of anesthesiology, orthopedic
surgery, and general surgery to be critical for the wartime need. 
However, physicians in these specialties historically leave the
military at faster rates than those in other specialties.  For
example, Navy officials estimate that, each year, the Navy loses
about 22 percent of physicians in these specialties, compared with an
annual 11 percent loss for all physicians.  A review of Army data
shows that a larger percentage of University graduates are retained
in these critical specialties than are graduates of the scholarship
program.\25 The Army data show that, on average, 31 percent of
University graduates in the three critical medical specialties will
stay 20 years, compared with 12 percent from the regular scholarship
program and 2 percent of deferred scholarship program graduates.\26


--------------------
\25 Neither the University nor the scholarship program train
graduates to be medical specialists. 

\26 DOD-wide data were not available. 


   DOD IS EVALUATING ITS OVERALL
   NEED FOR PHYSICIANS
---------------------------------------------------------- Chapter 5:2

DOD's ability to adapt to the changing nature of operational
scenarios and the challenges of providing cost-effective peacetime
health care will be key factors in determining physician needs for
the military.  Although recent DOD studies suggest that large
reductions have occurred in the overall number of physicians, these
studies do not indicate the optimal retention needed for physicians
from the various accession programs. 


      DOD STUDY SUGGESTS LOWER
      ACTIVE DUTY NEED
-------------------------------------------------------- Chapter 5:2.1

DOD's evaluations of its future physician needs have not led to
conclusions about the number of physicians required or optimal
retention patterns.  The catalyst for these evaluations was section
733 of the National Defense Authorization Act for fiscal years 1992
and 1993, which required DOD to conduct a study to, among other
things, determine (1) the size and composition of the military
medical system needed to support U.S.  forces during a war or other
conflict and (2) the adjustments needed for cost-effective delivery
of medical care to covered beneficiaries during peacetime.  DOD's
study (referred to as the 733 study) estimated that DOD has as many
as 3 times the number of physicians it needs during peacetime to meet
projected wartime requirements, as shown in table 5.1. 



                               Table 5.1
                
                 Active Duty Physician Requirements as
                       Portrayed in the 733 Study

                                                         733 study
                  Programmed for     733 study base   augmented during
                  fiscal year 1999        case           peacetime
----------------  ----------------  ----------------  ----------------
Active duty       12,600                 4,000             6,300
 physicians
Percent           Not applicable          -68%              -50%
 difference from
 1999 program
----------------------------------------------------------------------
The base case in DOD's study represents a 68 percent lower
requirement than DOD's fiscal year 1999 program plan suggests, but
refers only to those active duty physicians needed to administer care
to wartime casualties.  It excludes the additional numbers of
physicians needed for readiness during peacetime (the augmented
case).  In the augmented case, the study concludes that the number of
active duty physicians could be lower by 50 percent. 

The 733 study results immediately prompted a review by the services
of their physician needs.  Although the services have not disagreed
with the 733 study results, their individual efforts produced higher
estimates of physician needs, primarily because their reviews were
based on different assumptions than were used in DOD's study.  Our
review of the 733 study and the service's responses\27 found that
even if the services' assumptions are correct, the resulting
requirements for military physicians would be less than are currently
planned for in 1999.  The 733 study did not present a precise
estimate of DOD's needs or a precise guide for deciding which medical
personnel, units, and capabilities are no longer required.  Issues
such as these must be resolved before DOD can make decisions about
its retention needs. 


--------------------
\27 Wartime Medical Care:  Aligning Sound Requirements With New
Combat Care Approaches Is Key to Restructuring Force
(GAO/T-NSIAD-95-129, Mar.  30, 1995). 


      SOME DOWNSIZING HAS OCCURRED
-------------------------------------------------------- Chapter 5:2.2

Since 1991, the total active duty physician force has dropped about 4
percent, from about 14,200 in 1991 to about 13,700 in 1994.  Further
reductions to about 12,600 are scheduled by 1999 (11 percent
overall).  However, according to service officials in the Offices of
the Surgeon General, most of the reductions between 1991 and 1994
were due to the normal attrition of physicians through retirement,
resignations, and administrative leave.  Navy officials also said
some physicians were allowed to transfer from active duty to reserve
status, mostly as a result of base closures. 

These reductions in active duty physicians are slight when compared
with reductions in the entire force over the same period.  Between
1991 and 1994, total military endstrength dropped about 20 percent,
from 2.O million to 1.6 million, and is expected to drop to 1.45
million by 1999 (about 28 percent).  Service officials cited
congressionally imposed limits with respect to reductions of health
care personnel and DOD's continuing responsibility to provide care to
beneficiaries of DOD's health care system as reasons why greater
reductions have not occurred in the physician force. 


      DOD REQUIRED TO CERTIFY
      EXCESS NEED
-------------------------------------------------------- Chapter 5:2.3

Section 711 of the National Defense Authorization Act for fiscal year
1991 prohibits reductions in military (and civilian) health care
personnel below the number of such personnel serving on September 30,
1989, unless DOD certifies to the Congress that (1) the number of
personnel being reduced is in excess of current and projected needs
and (2) that the reduction will not increase costs in the $3.6
billion DOD-administered health insurance program for
beneficiaries--the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS).  DOD is also prohibited from reducing
the number of Navy active duty medical officers to fewer than 12,510
(including nonphysicians) unless DOD certification is accomplished. 

Our review of the DOD certification documentation for fiscal years
1991 to 1995 indicated that the Army has led in the reduction of its
physician force.  In fiscal year 1995, the Army was given authority
to reduce its physician force by 553 physicians after certifying this
number was in excess of their requirements and would not result in
increased CHAMPUS expenses.  The Assistant Secretary of Defense for
Health Affairs, as part of the fiscal year 1995 DOD certification,
requested the repeal of all legislative provisions that prohibit
medical staff reductions.\28 Officials in the Navy and Air Force
stated that they have not sought to reduce the number of physicians
because they have not been able to obtain and retain the targeted
number of physicians they believe they need. 


--------------------
\28 DOD officials said that the repeal was not granted for fiscal
year 1995, but is currently being discussed by the Congress. 


      TRICARE MAY AFFECT PEACETIME
      NEEDS
-------------------------------------------------------- Chapter 5:2.4

For several years, DOD has been testing alternative approaches to
delivering health care that increasingly incorporate managed health
care techniques.  In this regard, DOD recently established its
TRICARE program as an alternative to the traditional CHAMPUS
fee-for-service health insurance plan covering beneficiaries of
active duty members.  TRICARE is intended to provide an economical
source of medical care for all DOD beneficiaries even as medical
service endstrength is reduced.  A key component of TRICARE involves
contracting with civilian health care providers for beneficiary
health services.  If TRICARE is successful, it could result in a
reduced need for active duty physicians as more care is provided by
civilian contractors.  Progress made in the implementation of TRICARE
was one of the reasons mentioned by the Assistant Secretary of
Defense for Health Affairs for the proposed repeal of legislative
provisions that prohibit medical staff reductions. 


   FACTORS INFLUENCING PHYSICIAN
   RETENTION
---------------------------------------------------------- Chapter 5:3

University graduates are retained in the military at higher rates
than other accession sources largely because of their longer pay-back
obligations.  Also, some University students, such as those who
graduate from the military academies and the Reserved Officer
Training Corps (ROTC) programs, have existing obligations before
becoming University students.  Overall, many factors are associated
with the decision to make the military a career, including
demographic and personal concerns such as age and family
considerations, compensation, and nonphysician activities. 


      LONGER PAY-BACK REQUIREMENTS
      CONTRIBUTE TO HIGHER
      RETENTION OF UNIVERSITY
      GRADUATES
-------------------------------------------------------- Chapter 5:3.1

Although DOD's retention data indicate a relationship between
retention and accession source,\29 the data do not indicate the
reasons why these patterns occur.  However, the longer obligation
pay-back requirement is a key factor in the longer retention of
University graduates.  University graduates are expected to serve for
about 11 years after graduation, including GME training, before they
are first able to leave military service; compared to about 8 years
for the regular scholarship program and 4 years for deferred
scholarship program graduates.  This longer pay-back obligation
period is expected to lead many University graduates to decide to
serve another 9 years until they are able to retire.  University
officials said the longer retention may be partially due to their
recruitment criteria, under which they specifically attempt to select
people who express an interest in making the military a career. 
Hence, the longer retention is consistent with students' stated
intentions. 

Prior military obligation on the part of some of its students may
also influence University retention.  Two 1994 military studies\30

identified military academy backgrounds, prior military experience,
University attendance, and fellowship training\31 as predictive
factors in the retention of physicians in certain specialties.  About
21 percent of all students at the University have attended the
military academies or participated in ROTC programs.  We previously
reported that retention of these officers, regardless of profession,
is high.\32 Another 25 percent of all University students had prior
military experience in that they were either currently on active duty
at the time they enrolled or they had prior active duty or reserve
experience. 

Many of these predictive factors could apply to scholarship program
graduates as well.  For example, Army scholarship program officials
suggested that the retention experience of ROTC and military academy
graduates in the scholarship program is similar to that of University
graduates from the same sources.  Moreover, scholarship program
recruiters also look for people who are interested in making the
military a career.  Lower retention among deferred scholarship
program graduates has been attributed to the fact that they are
better able to network in the civilian sector during their civilian
GME programs and create private sector opportunities for themselves. 
One DOD official who has contributed to a number of DOD retention
studies believed the retention patterns for all physicians who stay
12 years is about the same, regardless of accession source. 


--------------------
\29 Retention rates also vary by service and medical specialty. 

\30 "Retention Rates and Retention Predictors Among Graduates of Army
Family Practice Residency Programs," Steinweg, Kenneth K., Journal of
Military Medicine, Vol.  159 (July 1994), pp.  516-519), and
"Retention of Internal Medicine Physicians in the U.S.  Army,
Zaloznik, Arlene J., Journal of Military Medicine, Vol.  159 (July
1994), pp.  520-523. 

\31 Fellowship training is advanced GME that prepares a physician for
a medical or surgical subspecialty. 

\32 Officer Commissioning Programs:  More Oversight and Coordination
Needed (GAO/NSIAD-93-37, Nov.  6, 1992). 


      OTHER FACTORS AFFECTING
      DECISIONS ABOUT A MILITARY
      CAREER
-------------------------------------------------------- Chapter 5:3.2

Many other factors influence physicians' decisions to stay in or
leave the military.  For example, personal characteristics, such as
age and sex, family considerations, and working conditions have all
been found to influence physicians' decisions.  More often than not,
financial considerations have been identified as a significant factor
in retention.  For example, in 1990, we conducted a survey of 1,500
military physicians to determine the factors that most influence
their decisions to leave the military.\33 Time spent on nonphysician
tasks and gaps between military and civilian compensation were the
most significant factors identified.  Physicians also reported
dissatisfaction with other aspects of military service, such as poor
hospital equipment, the inability to provide continuity of care to
patients, excessive amounts of quality assurance tasks, and limited
opportunities to attend professional meetings and training. 

Although many factors affect retention, a key DOD official involved
in DOD retention studies said that the options available to DOD to
change retention patterns are limited.  For example, there may be
little that can be done about dissatisfaction with quality assurance
procedures because these are needed for hospital accreditation.  The
official also said that even in those areas where DOD might have some
control, such as physician compensation, there are limits on the
amounts that DOD can pay.  Moreover, he believes that for some
medical specialties, DOD could not match the compensation that these
physicians could earn in the private sector. 

Other studies that examined why physicians stay in the military
identified the following reasons:  the availability of teaching
assignments and clinical research opportunities; lack of worry about
malpractice and office management problems; more control over working
hours; the collegial atmosphere of military medicine; and the
opportunity to travel. 


--------------------
\33 Defense Health Care:  Military Physicians' Views on Military
Medicine (GAO/HRD-90-1 Mar.  22, 1990). 


      ALTERNATIVE STRATEGIES TO
      MEET DOD'S LONG-TERM
      PHYSICIAN NEEDS
-------------------------------------------------------- Chapter 5:3.3

Proponents of the University note that the University meets DOD's
need for a small cadre of experienced military officers and leaders
who, in their opinion, are better prepared for the special needs of
military medicine.  If the University is closed and DOD continues to
need experienced career military physicians, DOD will need to find
alternative ways to extend the careers of some military physicians
while enhancing their exposure to military readiness training. 

One approach could involve an enriched component to the scholarship
program which would require a longer pay-back obligation for selected
students in return for additional benefits, training, and military
career opportunities.\34 Additional readiness training could be
provided through a post graduate period specifically designed to
enhance the physician's preparation for the special needs of military
medicine.  Through this type of two-tiered scholarship approach, DOD
could address its short- and long-term requirements for military
physicians. 


--------------------
\34 GAO did not determine if scholarship students would have been
willing to accept scholarships if their service obligation periods
were longer.  Under this alternative strategy, the current elements
of the scholarship program, including the service obligation
requirements, would not need to be changed for the majority of
scholarship applicants.  The change in service obligation
requirements could apply to a small subset of scholarship applicants
who would be specifically recruited for longer military careers. 


CONCLUSIONS
============================================================ Chapter 6

When the University and the scholarship program were authorized by
the Congress in 1972, following the end of the military draft, they
were intended to be complementary physician accession programs. 

  The University was established to meet the need for a small cadre
     of physicians who would be likely to become career military
     officers and leaders. 

  The scholarship program was authorized to provide a continuing and
     larger supply of military physicians who would, for the most
     part, not be expected to serve until their retirement. 

Notwithstanding the intended complementary nature of the two
physician accession programs, the comparative cost-benefit and
cost-effectiveness of the programs have been the subject of debate
ever since their authorization. 

Our prior work, this report, and several studies by other groups over
time show that by most measures the University program is a more
costly physician accession program than the scholarship program. 
Nevertheless, those who advocate the continuation of the University
make strong arguments that the need for a cadre of military physician
career officers and leaders remains, and that the University fulfills
that need well.  University supporters also note that in addition to
providing a high quality medical education, the University provides
other benefits such as medical research and archival programs,
required continuing medical education for overseas medical personnel,
and graduate education programs for allied health professionals. 
University officials stated that if the University were not
performing these tasks, other DOD components would have to be tasked
to carry them out. 

The early retention history for University graduates indicates that
the majority of them are still in the military and fulfilling their
service obligations.  Also, our review of DOD's retention analyses
shows that the University would likely continue to meet DOD's needs
for a cadre of military physician career officers.  However, based on
our review of available information, we believe that if the
University were closed, these needs could be fulfilled by alternative
strategies, such as adjusting the pay-back requirements of
scholarship students, revising the training approach for those
students to incorporate additional military unique training sessions,
or doing both. 

In our view, issues relating to the changed need for military
physicians in war and peacetime settings are important factors to be
considered as decisionmakers debate the future of both the University
and scholarship programs.  The changed wartime scenarios, which point
to a reduction in the number of physicians needed to meet contingency
requirements should, in our opinion, be taken into account as the
future existence and the possible size of the accession programs are
determined.  Moreover, DOD's attempt to meet its peacetime care
obligations to military beneficiaries through increased reliance on
its TRICARE managed care program will also affect the number and type
of physicians that DOD needs. 


   MATTER FOR CONGRESSIONAL
   CONSIDERATION
---------------------------------------------------------- Chapter 6:1

The Administration's National Performance Review has proposed that
the University be closed.  This proposal has presented the Congress
with difficult policy decisions regarding the need for a cadre of
physicians who are likely to become career military officers and the
most appropriate means of retaining those physicians. 

As Congress makes those decisions, it may wish to consider requiring
DOD to justify both the University and the scholarship program in the
context of DOD's specific short- and long-term requirements for
military physicians, the role of the University and the scholarship
program in satisfying those requirements, and their relative costs. 


   AGENCY COMMENTS
---------------------------------------------------------- Chapter 6:2

We obtained comments on a draft of this report on September 15, 1995,
from the Assistant Secretary of Defense, Health Affairs, and his
staff and from the University's President and other top University
officials. 

The Assistant Secretary stated that the report presents a great deal
of factual data and reflects a significant research effort in its
collection and compilation.  Both the Assistant Secretary and
University officials were concerned, however, about several
presentational issues including what they viewed as

  a focus in our comparative cost analysis on the cost per graduate
     of each program, rather than on the total cost to the taxpayer
     per staff year of DOD service, which they believe is the
     appropriate measure of cost;

  a lack of emphasis on the activities of the University, which
     results in cost-avoidance for other DOD components; and

  a lack of emphasis on the University's unique contribution to
     providing military physicians schooled in militarily unique
     medical subjects and our failure to acknowledge the
     "acculturation process" provided by the University in meeting
     the needs of military medicine. 

In response to our matter for congressional consideration, the
Assistant Secretary stated that, although the position of the
Administration and the Department is that the University should be
closed, the Department noted our recognition of the different goals
of the two programs and their complementary nature.  He also stated
that the Department does not believe additional justification is
needed for the University and scholarship program and that the need
for a long-term experienced cadre of military physicians produced by
the University and short-term physicians will continue. 

Regarding the first concern of DOD and the University, we recognized
that there can be and, in fact, have been several units of
measurement used to compare the relative costs of DOD's physician
accession programs.  Rather than offering one unit of measurement, we
have presented, in an iterative way, several units of measurement
that we believe present a complete comparative analysis of the
programs. 

We have revised the report to further emphasize the cost-avoidance
activities of the University but, as stated earlier, we did not
validate the University's estimates of cost-avoidance. 

The Assistant Secretary and University officials were concerned that
we had not appropriately emphasized the University's unique
contribution to military medicine.  In response, we have revised the
report to reflect the University's approach to providing a complete
education in military medicine and made minor adjustments to the
draft report.  These adjustments were designed to attribute
statements about the unique needs of military medicine and the
University's contributions without appearing to question the
credibility of our sources.  However, we believe that judgments
regarding the relative emphasis placed on various issues discussed in
the report must be based on the evidence at hand.  In this case, the
evidence was based primarily on our review of military medical
literature and discussions with military medical personnel who
provided their opinions regarding the uniqueness of military
medicine. 

Finally, in developing the matter for congressional consideration, we
did not envision that DOD would have to provide additional
justification for the accession programs.  Rather, we believe that
the two programs need to be discussed in the context of DOD's
specific short- and long-term requirements for military physicians so
that decisions regarding the continued need for the programs and
their relative sizes can be made with confidence that the
requirements will be adequately met. 

Department and University officials offered several technical
comments on our draft report that we incorporated into the final
report as appropriate. 


OBJECTIVES, SCOPE, AND METHODOLOGY
=========================================================== Appendix I

The National Defense Authorization Act for fiscal year 1995 directed
us to submit a detailed report to the Congress on the University. 
More specifically, the report was to include the following: 

  a comparison of the cost of obtaining physicians for the Armed
     Forces from the University with the cost of obtaining physicians
     from other sources;

  an assessment of the retention rate needs of the Armed Forces for
     physicians in relation to the respective retention rates of
     physicians obtained from the University and physicians obtained
     from other sources and the factors that contribute to retention
     rates among military physicians obtained from all sources;

  a review of the quality of the medical education provided at the
     University with that provided by other sources of military
     physicians;

  a review of the overall issue of the special needs of military
     medicine and how these special needs are being met by physicians
     obtained from the University and physicians obtained from other
     sources;

  an assessment of the extent to which the University has responded
     to the 1990 report of DOD's Inspector General including
     recommendations for resolution of any continuing issues relating
     to management and internal fiscal controls of the University,
     including issues relating to the Henry M.  Jackson Foundation
     for the Advancement of Military Medicine identified in the 1990
     report; and

  any other recommendations that the Comptroller General considers
     appropriate. 

The methodology for our review is discussed below. 


   COST OF OBTAINING PHYSICIANS
--------------------------------------------------------- Appendix I:1

Our review of the costs of obtaining physicians for the military
focused on the historical educational costs for the graduating class
of 1994 and the projected postgraduation costs for additional
training (including GME and initial medical readiness training),
salary, and retirement costs.  In a supplemental analysis, we
included a proportional amount of (non-DOD) federal funds provided to
civilian medical schools and the University for research and GME
programs.  We reviewed studies conducted by DOD, the University, GAO,
and others on various aspects of medical education costs, including
civilian undergraduate and graduate medical education.  We held
discussions with officials of DOD, the University, and the
Association of American Medical Colleges on the relevant cost
elements to be included.  We included elements that contribute to the
cost of obtaining and retaining physicians and we attempted to ensure
comparability between cost elements in the programs. 


      DETAILED DISCUSSION OF COST
      METHODOLOGY
------------------------------------------------------- Appendix I:1.1

Having determined our base year, unit of analysis, and cost elements,
we determined (1) the total cohort associated with the graduating
class of 1994 and (2) the percentage of yearly costs to be applied to
the cohort. 


      TRACKING THE 1994 COHORT
------------------------------------------------------- Appendix I:1.2

The total cohort included: 

  the original members of the class of 1994 that entered in 1991;

  extended matriculations from prior years (5- or 6-year students who
     were scheduled to graduate with past classes, but who graduated
     in 1994); and

  student attrition (students who were scheduled to graduate in 1994,
     but who dropped out of medical school). 

We did not include the original members of the graduating class of
1994 who, at the time of our analysis, were expected to graduate in a
subsequent class.  Under our methodology, the cost of these students
would be included in the costs of the class in which they graduate. 

The University was able to provide all data needed to determine the
total cohort, while the scholarship program officials in the services
had varying success.  Scholarship program officials were not able to
provide useful data on the extended matriculations in the graduating
class of 1994.  However, they also said that they did not provide
additional years of scholarship for 5- or 6-year students.  Army
officials were not able to provide attrition data by year.  Navy
officials did not provide any attrition data.  We averaged the
attrition from the Army and Air Force programs and applied it to the
Navy.  Table I.1 illustrates the tracking of the 1994 cohort for the
University. 



                               Table I.1
                
                Yearly Tracking of Cohort Group Members
                 at the University (Fiscal Years 1989-
                                  94)

                                                                  1994
                                      19  19  19  19  19  19  graduate
Starting year                         89  90  91  92  93  94         s
------------------------------------  --  --  --  --  --  --  --------
1989 (6)                               1   1   1   1   1   1         1
1990 (5)                               -  15  15  15  15  15        15
                                       -
1991 (4)                               -   -  14  14  14  13       139
                                       -   -   9   2   2   9
Yearly 1994 cohort                     1  16  16  15  15  15       155
                                               5   8   8   5
======================================================================
Total students                        66  66  67  64  65  67        --
                                       0   7   3   8   8   1
----------------------------------------------------------------------
The table shows that the 1994 graduating class at the University had
16 extended matriculations from previous years.  Also, 13 members
from the original freshman class (162) were excluded because, at the
time of our analysis, they were scheduled to graduate in subsequent
years.  As a result, the start year 1991 shows 149 students instead
of 162 students.  There were 10 students from the original class of
1994 (start year 1991) who dropped out of medical school altogether. 
Seven dropped out after the first year and 3 dropped out after the
third year. 


      SCHOLARSHIP PROGRAM COHORT
      TRACKING
------------------------------------------------------- Appendix I:1.3

Because scholarship program officials were not able to provide
meaningful data on the number of 5- or 6-year students who graduated
in 1994, the size of the yearly scholarship program cohort was
largely determined by the length of the scholarship.  Table I.2
illustrates how we tracked the scholarship program cohorts, using the
Navy as an example. 



                               Table I.2
                
                Yearly Tracking of Size of Cohort Group,
                 Navy Scholarship Program (Fiscal Years
                                1991-94)

                                                                  1994
                                                                gradua
Award year                        1991    1992    1993    1994     tes
------------------------------  ------  ------  ------  ------  ------
1991 (4)                           187     175     175     175     175
1992 (3)                            --     149     149     149     149
1993 (2)                            --      --      14      14      14
1994 (1)                            --      --      --       1       1
======================================================================
Total cohort                       187     324     338     339     339
======================================================================
Total scholarships               1,350   1,206   1,273   1,348      --
----------------------------------------------------------------------
The table shows that the Navy provided scholarships of 4, 3, 2, and 1
years.  For example, a 4-year scholarship started in 1991, while a
3-year scholarship started in 1992.  Regardless, these start years
led to a 1994 graduating date.  We assumed that the Navy scholarship
program experienced all of its attrition after the first year. 


      YEARLY COSTS TO THE COHORT
------------------------------------------------------- Appendix I:1.4

Having determined the size of the cohort in any year that a cohort
member was present, we then determined allocation factors to be used
to apportion a percentage of each program's yearly educational costs
to the cohort.  The allocation factors represent the yearly
percentage of cohort members to the total number of scholarships or
students at the University in any given year.  For example, using the
Navy table above, 187 members of the 1994 cohort were among the 1,350
scholarships in 1991.  The percentage of the Navy's fiscal year 1991
costs applied to the 1994 cohort is represented by the fraction
187/1,350.  In fiscal year 1992, the cohort lost 12 students, but
gained 149 3-year scholarships.  Hence, the percentage of 1992 costs
applied to the 1994 cohort is represented by the fraction 324/1,206. 
We calculated these percentages for each year that a member of the
cohort was present in the scholarship program and at the University. 


      ALLOCATING COST TO THE
      DEFERRED PROGRAM
------------------------------------------------------- Appendix I:1.5

We allocated the educational and initial readiness training costs to
the deferred and regular scholarship programs using a four-step
process.  We first calculated the individual service's educational
and initial readiness training cost for the scholarship program as a
unified program.  We totaled the service costs and multiplied the
total by the ratio of deferred to total scholarship program students
and the ratio of regular scholarship program participants to total. 
This same process was used to determine the initial readiness
training costs to be applied to each program, because there was no
difference in costs for this training. 


      ADDITIONAL FEDERAL COSTS TO
      THE SCHOLARSHIP PROGRAM
------------------------------------------------------- Appendix I:1.6

A portion of federal expenditures that support civilian medical
education may be incurred to augment the supply of military
physicians.  Identification of those expenditures, however, is
problematic. 

The federal government supports civilian medical education in two
primary ways.  Medicare provides direct and indirect payments to
teaching hospitals to defray the costs of resident training.  These
amounts totaled about $6.2 billion in 1994.  The National Institutes
of Health (NIH) and other federal agencies provide funding for
biomedical research, largely at the undergraduate level.  In 1994,
NIH provided about $5.7 billion to support research in medical
schools.  Officials at the AAMC suggested that these monies could be
applied directly to medical school programs for the purpose of this
analysis. 

An apportionment of Medicare GME monies to reflect the funds incurred
to augment the supply of military physicians should reflect the
fraction of these scholarship students' expected practice lives that
will be spent in the military versus the civilian sector.  Estimates
of the expected length of civilian practice for military physicians
is not easily obtainable, especially for University graduates. 
However, the expected length of military practice is about 5.3 years
for deferred scholarship students, 9.8 years for regular scholarship
students, and 18.45 years for University students.  Lacking the data
on expected civilian practice duration, we apportioned Medicare GME
monies based on the number of deferred scholarship residents and
University graduates who attended civilian GME programs relative to
the total, and on the expected length of their military careers. 
This apportionment, thus, overstates the Medicare GME expenditures
that should be attributed to DOD for preparation of medical students
for military service.\35

Apportionment of the research funding received by medical schools
should reflect the expected length of military versus civilian
practice.  Further, the apportionment should only include those
research funds that are directly or indirectly essential to
maintaining an effective undergraduate medical education program. 
Again due to the absence of data on expected practice lives and on
the portion of research funds essential to maintaining schools'
medical educational program, we apportioned the research monies based
on the total number of scholarship students compared with the total
number of medical school students for each year from 1991 to 1994,
and on the expected length of their military careers.  This
apportionment also likely overstates the research funding that should
be attributed to DOD for preparation of scholarship students for
military service. 


--------------------
\35 Similarly, in this context, the costs to DOD for preparing
University students is overstated, given the fact that University
graduates can be expected to spend a portion of their medical careers
in civilian practice. 


   DOD'S RETENTION RATE NEEDS
--------------------------------------------------------- Appendix I:2

To understand DOD's need for physicians, we interviewed and obtained
documentation from the Office of the Assistant Secretary of Defense,
Health Affairs, and the Offices of the Surgeons General for each
service in order to understand (1) their processes for determining
the number and types of physicians required to fulfill their missions
and (2) the impact of DOD's downsizing on the physician force levels. 
As part of this effort, we held additional discussions with officials
who were examining some of these issues in PA&E and members of the
DOD Roles and Missions Commissions. 

To assess how well physicians from the various accession sources
served the needs of DOD, we supplemented our discussions with the
medical planners in the Offices of the Surgeons General with
interviews and data gathered in the Office of the Assistant Secretary
of Defense, Health Affairs, and the Defense Data Manpower Center
pertaining to the historical retention of physicians by accession
source, military service, and medical specialty.  The Office of the
Assistant Secretary of Defense, Health Affairs, also provided copies
of several published and unpublished studies and provided data
pertaining to the retention of physicians.  The service level
officials that we contacted all agreed that we should use these
numbers to discuss the historical and projected retention patterns of
DOD physicians. 

To examine the factors that influence physicians' decisions to remain
in or leave the military, we obtained and reviewed studies from
numerous sources dating back to the 1970s.  Appendix III is a listing
of these studies. 


   QUALITY OF MEDICAL EDUCATION
--------------------------------------------------------- Appendix I:3

To determine how the quality of medical education provided by the
University compares with that obtained by other military physicians,
we identified generally accepted measures of medical education
quality through a review of the literature.  We also held discussions
with and reviewed documentation provided by representatives of the
University as well as the accrediting body for U.S.  schools of
allopathic medicine--LCME--which is a joint activity of the AAMC and
the Council on Medical Education of the American Medical Association. 
We discussed the identified measures with representatives of the
Surgeons General of each military service and the Office of the
Assistant Secretary of Defense, Health Affairs.  Among the measures
identified, we assessed the following:  the accreditation status of
the school, the academic credentials of the students that the school
admits, performance on standardized tests, performance upon
graduation, and negative indicators of quality. 

We also examined documentation provided by the University concerning
its accreditation by LCME as well as the Middle States Association of
Colleges and Schools, which accredits institutions of higher
learning.  We met with a representative of LCME to discuss the
significance of concerns raised during its most recent accreditation
review of the University's School of Medicine and the response of the
University to these concerns. 

Representatives from the University and LCME said that the academic
credentials of the students that a medical school attracts are
considered an indirect reflection of the medical school's quality. 
Two widely used objective measures of academic achievement among
medical school applicants are undergraduate GPAs and scores on MCAT. 
The University provided average MCAT scores and GPAs for University
students and for medical students nationwide (access to nationwide
records is available to the University as a result of its membership
in AAMC).  The Army and Navy provided these averages for scholarship
program participants, but the Air Force was unable to do so. 

We used scores on the USMLE, a standardized test used by all 50
states as part of the physician licensing process, as a basis for
comparison of medical education across all U.S.  medical schools. 
The University provided average scores and pass rates for its
students and for medical students nationwide for each of the three
parts of the test. 

To compare how well University graduates and scholarship program
graduates perform at the beginning of their medical careers, we
examined a sample of performance evaluations completed by supervisors
of interns from the University and other schools in military GME
programs at the Air Force's Malcolm Grow Medical Center at Andrews
Air Force Base, Maryland; the Walter Reed Army Medical Center in
Washington, D.C.; and the National Naval Medical Center in Bethesda,
Maryland.  Because intern performance evaluation procedures vary from
program to program, we were not able to examine the performance of
interns beyond these three hospitals.  The results of our analysis
cannot be projected to any other group of interns.  We also contacted
the commanders of 33 of the largest military medical treatment
facilities to obtain their perceptions about the relative clinical
performance of University graduates and other military physicians. 

Finally, the Armed Forces Institute of Pathology provided information
concerning the number of adverse clinical privileging actions
occurring among graduates of the University and graduates of other
medical schools.  The Institute provided the absolute number of
actions for each group for the period 1982 through 1994.  We combined
that information with data about the number of physicians on active
duty during that period to determine the number of actions per 1,000
physician staff years. 

The officials with whom we met suggested certain other indicators of
medical education quality that we did not include in our analysis. 
For example, University officials suggested that we consider the rate
at which University graduates get their first choice among the
service's GME programs--a measure favorable to the University whose
graduates have a very high first-choice rate.  While the Army and Air
Force also track this measure, its usefulness is limited in that
University graduates receive counseling in choosing a GME program,
with the result that they are less likely to make inappropriate
choices (that is, to select a GME program for which they are not
competitive).  Scholarship program participants would not routinely
have access to such counseling.  Another measure suggested but not
included in our analysis is board certification status of University
graduates compared with graduates of other medical schools.  Although
this measure is important to the services, it may be more reflective
of the GME program, rather than the undergraduate program that the
physician attends. 


   SPECIAL NEEDS OF MILITARY
   MEDICINE
--------------------------------------------------------- Appendix I:4

We used several techniques to identify the ways in which military
medicine differs from the practice of medicine in a peacetime setting
and how military physicians are prepared for these unique aspects of
military medicine.  We collected information through a literature
search and through contacts with and documentation provided by
officials throughout DOD including the Office of the Assistant
Secretary of Defense, Health Affairs; the Joint Staff; the
University; the offices of the Surgeons General for each military
service; the DOD Inspector General; training activities throughout
DOD; and commanders of some of the largest military medical treatment
facilities and selected deployable medical units. 

Through discussions with DOD officials, we identified the training
required for new military physicians (basic officer training) and the
training that most new military physicians initially receive after
coming onto active duty (the Combat Casualty Care Course or similar
training).  Then, working with University officials and
representatives of each of these training courses, we compared the
medical readiness content of the training that University medical
students receive during medical school with that which
civilian-educated physicians would have after they complete basic
officer training and the Combat Casualty Care Course. 

We asked DOD officials to identify measures that would indicate the
relative effectiveness of the University program to the approach used
to provide medical readiness training to military physicians who are
graduates of civilian medical schools.  Officials suggested that in
the absence of specific measures of physicians' preparedness to meet
the special needs of military medicine we consider other indicators
such as physician promotion rates, types of assignments held, awards
received, and levels of professional military education attained. 

We examined but, for several reasons, rejected using these measures
in our report.  For example, in examining a selection of records, we
found that they contained many inaccuracies.  In addition,
information about the type of assignment held was often ambiguous;
thus, it was not clear if a physician was serving in a capacity that
was primarily clinical or primarily operational in nature.  Using the
number of awards received or levels of professional military
education attained could unfairly favor University graduates because
many served in the military before they attended the University. 
Finally, promotion data did not exist in a format that would permit
meaningful comparisons. 

Because objective evidence is lacking concerning the relative
effectiveness of the University approach and other readiness training
in preparing physicians for the special needs of military medicine,
we sought the perspectives of leaders in military medicine.  Through
the Joint Staff and the offices of the Surgeons General of each
service, we posed questions to the Command Surgeons of each of the
unified commands, the commanders of 33 of the largest military
medical treatment facilities, and the commanders of 18 of the Army's
deployable medical units.  In total, we queried 61 commanders, 44 of
whom provided their opinions about the University and other military
physicians regarding their overall clinical capabilities and their
preparedness for the special needs of military medicine. 


   RESPONSES TO INSPECTOR GENERAL
   RECOMMENDATIONS
--------------------------------------------------------- Appendix I:5

To determine the progress that the University has made in addressing
the recommendations made in 1990 by the DOD Inspector General, we
discussed the report, its recommendations, and corrective actions
with representatives of the University, the Henry M.  Jackson
Foundation, and the Inspector General.  We also reviewed corrective
action documentation that they provided and discussed with
representatives of the Inspector General plans for followup to their
1990 report. 


   OTHER CONTRIBUTIONS OF THE
   UNIVERSITY
--------------------------------------------------------- Appendix I:6

To identify functions of the University other than the medical
education it provides its students, we reviewed documentation
provided by the University, including correspondence, program
descriptions, year-end reports, and other documents.  We also
interviewed officials at the University, including its President, the
Dean of the School of Medicine, department chairs, research office
representatives, and various other program officials.  We also
observed portions of its training program for emergency medical
technicians as well as a continuing medical education seminar for
physicians.  Finally, we sought the opinions of commanders of major
military medical units regarding any benefits that they believe
derive from the University beyond the medical education it provides. 

To identify school functions that are important for educating medical
students, we interviewed an official from LCME and reviewed its
standards for accreditation. 


COMPARISON OF HOURS SPENT IN
INITIAL MEDICAL READINESS TRAINING
========================================================== Appendix II

As part of its 4-year medical school curriculum, the University
provides coverage of many topics related to the special needs of
military medicine.  Physicians who are graduates of civilian medical
school receive such training in basic officer training or the Combat
Casualty Care Course (C4).  The following table shows the number of
classroom hours spent in each area by initial readiness training
source.  The subjects are grouped into those that are primarily
medical and those that are primarily military.  Within each of those
groupings, the subjects are arranged in descending order according to
the amount of coverage that the University provides.  As mentioned
previously, University students are required to attend the basic
officer training for their service branch.  Thus, in addition to the
amount of coverage that the University provides, for example, 26
hours in medico-legal issues, an Army physician who graduates from
the University will receive additional training (12 hours, in this
case) by attending basic officer training.  (Field training hours for
C4 are included within the other subjects shown in the table.)



                               Table II.1
                
                  Comparison of Hours Spent in Initial
                       Medical Readiness Training

                                                  Navy     Air
                                        Army\\  basic\  force\
Medical subjects                  USU\   basic       \   basic      C4
------------------------------  ------  ------  ------  ------  ------
Tropical medicine                 66.0     0.0     0.0     0.0     0.0
Weapons effects                   59.0     0.0     0.0     0.5     0.0
Combat medical skills             41.5     2.0     0.0     7.0    18.5
Nuclear, biological, and          30.0    15.0     0.0     5.5    12.5
 chemical warfare
Military preventive medicine      26.5     3.0     0.0     0.5     4.5
Advanced trauma life support      26.0     0.0     0.0     0.0    20.0
Military psychiatry               22.5     8.0     2.0     1.0     1.5
Environmental threats             21.5     0.0     0.0     0.0     0.0
Advanced cardiac life support     20.0     0.0     0.0     0.0     0.0
Military disease and injury       18.5     0.0     0.0     0.0     1.5
Special infectious diseases       15.0     0.0     0.0     0.0     0.0
Subtotal                         346.5    28.0     2.0    14.5    58.5

Military subjects
----------------------------------------------------------------------
Field training exercise          240.0    81.0     0.0     8.0     0.0
Defense studies and military      42.5    11.0    23.0     2.5     1.5
 operations
Military field studies            35.0    12.0     0.0     0.0    11.5
Military organization and         27.0    10.0    36.0    23.0    10.0
 administration
Medico-legal issues               26.0    12.0    10.0     1.0     0.0
History of military operations    17.0     1.0     2.0     1.0     0.0
Subtotal                         387.5   127.0    71.0    35.5    23.0
======================================================================
Total                            734.0   155.0    73.0    50.0    81.5
----------------------------------------------------------------------

STUDIES OF FACTORS AFFECTING
RETENTION OF MILITARY PHYSICIANS
========================================================= Appendix III

Cost Effectiveness Analysis of Two Military Physician Procurement
Programs:  The Scholarship Program and the University Program
(GAO/MWD-76-122, May 5, 1976). 

Federal Cost of the HPSP Program (GAO/HRD-76-140, June 15, 1976). 

Physician Retention and the Cost-Effectiveness of the Uniformed
Services University of the Health Sciences; DOD/Office of the
Assistant Secretary of Health (Program Analysis and Evaluation) (July
1991). 

The Cost of Physicians Accessions; Bircher, J.  and Redman, R; Health
Studies Task Force, Office of the Assistant Secretary of Defense,
Health Affairs (Oct.  1987). 

The Cost of Physicians Accessions; Prepared for the Senate Armed
Services Committee; Bircher, John; Office of the Assistant Secretary
of Defense, Health Affairs (Jan.  1988),

Physician and Dentist Retention; Bircher, John; Health Studies Task
Force; Office of the Assistant Secretary of Defense, Health Affairs
(Dec.  1986). 

Cost Analysis of the Military Medical Care System:  Final Report;
Institute for Defense Analysis (Sept.  1994). 

Military Health Services System Strategic Plan for Graduate Medical
Education; Office of the Assistant Secretary of Defense, Health
Affairs (Mar.  1994). 

Graduate Medical Education Literature Abstracts; GME:  A Review of
the Literature, Vector Research Inc.  (Jan.  3, 1995). 

Savings and Costs from Using the "Air Force Model" of GME, Carey,
Neal, Center for Naval Analysis (Feb.  8, 1995). 

The Cost of Graduate Medical Education, Bircher J., and Ziskind B.;
Office of the Assistant Secretary of Health, Health Affairs, Health
Studies Task Force (1986). 

Graduate Medical Education and Military Medicine, Institute of
Medicine (July 1981). 

Plan For Improving and Consolidating GME, Office of the Assistant
Secretary of Defense, Health Affairs (May 1992). 

A Comparison of USUHS School of Medicine Graduate and the Health
Profession Scholarship Program Graduate in their First Year of GME: 
A Descriptive Study, Chagallis, George, dissertation, (Feb.  20,
1984). 

Military GME Under Stress:  A White Paper, Society of Medical
Consultants to the Armed Forces (Oct.  1987). 

Fourth Report of the Council on Graduate Medical Education to the
Congress and the Secretary, Department of Health and Human Services,
Council on Graduate Medical Education (Jan.  1994). 

Measuring the Impact of the Navy's Downsizing on Medical Officers
Billets Levy, R., and Carey, N.; Center for Naval Analyses (Nov.  18,
1993). 

Defense Health Care:  Military Physicians Views on Factors Which
Influence Their Career Decisions (GAO/T-HRD-89-10, Mar.  16, 1989). 

Defense Health Care:  Military Physicians' Views on Military Medicine
(GAO/HRD-90-1, Mar.  22, 1990). 

Retention Rates and Retention Predictors Among Graduates of Army
Family Residency Programs; Steinweg, Kenneth K.; " Journal of
Military Medicine," Vol.  159 (July 1994), pp.  516-519. 

Retention of Internal Medicine Physicians in the U.S.  Army;
Zaloznik, Arlene; "Journal of Military Medicine," Vol.  159 (July
1994), pp.  520-523). 

An Analysis of Factors Affecting The Retention of Medical Officers in
the United States Navy, Whalen, William P.; Naval Postgraduate
School, (master's thesis) (Dec.  1986)

Correlations of Physician Retention at Tripler Army Medical Center,
Thomas, Brennand; U.S.  Army War College, master's thesis (Dec. 
1991). 

Socioeconomic and Personal Variables Effecting Retention of Medical
Officers; Cain, Russell L.; Naval Post-Graduate School, master's
thesis (Dec.  1986). 

Medical Manpower Shortages and the Retention of Navy Physicians; May,
L., Graham, A., and Dolfini, J; Center for Naval Analyses (Mar. 
1989). 

The Impact of the All-Volunteer Force on Physician Procurement and
Retention in the Army Medical Department, 1973-1978; Brooke, Paul,
U.S.  Army War College, master's thesis (June 8, 1979). 

Retention of Volunteer Physicians in the U.S.  Air Force; Daubert,
Victoria L.; RAND Corporation (Feb.  1985). 

A Turnover Analysis for Department of Defense Physicians; Gaffney,
James K.; Naval Post-Graduate School, master's thesis (Dec.  1986). 

A Retention Model for Navy Physicians; McMahon, J.; Center for Naval
Analyses (June 1989). 

A Multivariate Analysis of Navy Physician Retention; Franco, Richard
P.; Naval Post-Graduate School, master's thesis (Dec.  1989). 

Retention of Navy Physicians, FY 1984-1988; May, L.  and Graham, A.;
Center for Naval Analyses (June 1989). 

U.S.  Air Force Physician Retention; Rodgers, Lee P.; Air War
College, master's thesis (Apr.  1990). 

Recommendations for Improving the Bureau of Medicine Information
System May, L., Graham, A.; and McMahon, J.; Center for Naval
Analyses (June 1989). 

Procurement and Retention of Navy Physicians Divine, Eugene J.;
Center for Naval Analyses (Nov.  1973). 


RESPONSES OF THE UNIFORMED
SERVICES UNIVERSITY OF THE HEALTH
SCIENCES TO THE INSPECTOR
GENERAL'S RECOMMENDATIONS
========================================================== Appendix IV

The DOD Inspector General (IG) reviewed the University in June and
July 1989 to evaluate the adequacy of the University's planning and
program execution and to assess the effectiveness of its oversight
and management controls.  In its April 1990 report, the IG
recommended corrective actions in six categories:  (1) management and
organizational oversight, (2) finance, (3) personnel, (4)
acquisition, (5) information resources, and (6) laboratory animal
medicine.  In October 1994, the IG closed the inspection based on the
University's corrective actions reported over a 4-year period.  A
summary of the IG findings and the response from the University
follows. 


   MANAGEMENT AND ORGANIZATIONAL
   OVERSIGHT
-------------------------------------------------------- Appendix IV:1

The IG's report made nine recommendations dealing with the
University's management and organizational oversight.  These
recommendations covered issues involving (1) the need for
improvements in internal controls; (2) participation in operational
and research projects in foreign countries without formal, written
agreements; (3) failure to implement an effective drug testing
program; and (4) failure to use commercial entities for services
whenever appropriate, in accordance with the Office of Management and
Budget's (OMB) Circular A-76. 


      INTERNAL CONTROLS
------------------------------------------------------ Appendix IV:1.1

The legislation authorizing the University allows the Board of
Regents to enter into contracts with the Henry M.  Jackson
Foundation, a congressionally established not-for-profit organization
for the advancement of military medicine.  The legislation allows the
Board to furnish the services of professional, technical, or clerical
personnel and to make University facilities, equipment, space, and
support services available to the Jackson Foundation.  The IG found
that the University had assigned personnel to perform the same work
for the Jackson Foundation as they did for the University.  By doing
so, the University created an appearance of a conflict of interest
and eliminated essential internal controls governing the separation
of authority, duty, and responsibility. 

For example, the president of the University, at the time of the IG
inspection, was a director and served as the secretary and treasurer
of the Jackson Foundation.  As the University president, he had the
responsibility and authority to manage and control all University
resources, including research programs, and to oversee the
administrative functions.  At the Jackson Foundation, he directed the
day-to-day business and entered into contracts, leases, and
cooperative agreements. 

According to the IG, the University is subject to DOD's internal
management control program, which is designed to provide necessary
controls over the accountability and utilization of DOD resources to
prevent instances of fraud, waste, and abuse.  The University was
required to evaluate its internal controls and rate identified
assessable units from high- to low-risk vulnerability.  In the
assessment done in 1986, the University found no weaknesses, and all
units were rated low-risk.  This occurred again in 1988, shortly
before the IG's inspection.  The IG could find no documentation to
indicate that the internal management control systems were tested in
several critical functional areas, such as logistics; contracting;
the care, treatment, and security of animals used in training and
research; and pharmaceutical management. 

In December 1990, DOD issued a policy statement on the support and
resources shared between the University and the Jackson Foundation. 
In 1991, a general operating agreement and several subagreements
between the University and the Jackson Foundation were signed. 
However, support provided by the University to the Foundation or by
the Foundation to the University in the same functional area require
separate subagreements.  Billing schedules are quarterly and are paid
in full.  Additionally, 34 Jackson Foundation administration
positions were reviewed and 7 converted to federal civil service. 

The Naval Academy's internal control system was used to shape a
similar system for the University, an internal control plan for
implementation of the Federal Manager's Financial Integrity Act was
established, and mid- and long-range plans were developed. 


      INTERNATIONAL AGREEMENTS
------------------------------------------------------ Appendix IV:1.2

Under Public Law 92-426 as amended, the Board may enter into
agreements with foreign military medical schools for reciprocal
education programs.  The procedures to establish an agreement for
student exchange or a joint research program begin with informal
discussions between the University and foreign country
representatives.  A formal agreement is prepared by the University's
General Counsel and is approved by the Board.  The agreement is then
coordinated through the Deputy Director for International Affairs;
the Office of the Assistant Secretary of Defense, Health Affairs; and
DOD's General Counsel.  The Secretary of Defense signs the agreement
after completion of the coordination. 

The IG found that the University was actively engaged in research
projects in countries that had no existing DOD-approved agreements. 
Agreements with Belize, Pakistan, and the People's Republic of China
had been in the coordination phase at the Office of the Secretary of
Defense for up to 2 years at the time of the IG inspection. 
University medical researchers regarded these delays as a reason to
begin work on their projects without waiting for approval.  They were
managing these projects based solely on informal arrangements.  The
President of the University approved and supported these projects
with DOD resources.  The Board had the responsibility to consider the
ramifications of conducting operations in a foreign country without a
formal agreement. 

The University subsequently established procedures to comply with DOD
requirements.  The new procedures provide that no government
resources be committed until an approved agreement is signed.  The
approval process requires the University's General Counsel to collect
and assemble the agreement package and provide simultaneous copies to
the Office of the Assistant Secretary of Defense, Health Affairs, and
DOD's General Counsel.  The University's Board of Regents requires
that all proposed international agreements be provided to the Board
before the start of negotiations and again once negotiations have
been completed, but before implementation. 

The University also entered into memoranda of understanding with the
governments of Belize and Pakistan.  The University determined that
its activities in Zambia were adequately covered by specific
contracts.  No agreement was concluded with China and no operations
or resources were committed there.  According to a University
official, the University currently has agreements with Canada,
Denmark, Pakistan, the United Kingdom, and Israel. 


      DRUG TESTING
------------------------------------------------------ Appendix IV:1.3

Programs to ensure a drug-free work place are required by DOD for the
safety, health, and productivity of its employees and the public they
serve.  The Secretary of Defense directed each of the services to
develop drug abuse prevention and control programs. 

The University, as part of the DOD medical community, should place
special emphasis on drug programs.  The IG, however, found that an
inadequate number of military personnel assigned to the University
had been tested for drugs.  As a result, the University updated its
procedures for the drug testing of all military personnel assigned to
it, with the goal of testing 100 percent of the military personnel at
least once a year.  The implemented instructions contain internal
control provisions that assure appropriate action is taken by the
University or the military services when a drug test proves positive. 

In April 1990, the University also implemented procedures for the
drug testing of certain civilian employees (Chairman, Board of
Regents members, all persons with top secret security clearances,
motor vehicle operators, and faculty members who handle or manage
controlled drugs).  Currently, 194 civilians are subject to drug
testing out of an employee work force of approximately 800. 


      OMB CIRCULAR A-76
------------------------------------------------------ Appendix IV:1.4

OMB Circular A-76 requires reliance on commercially available sources
to provide products and services that the government needs.  DOD
supports the policy through its commercial activities program.  DOD
components have been directed to implement the program, designate a
program office, complete an inventory of all commercial functions,
and report program data to the Under Secretary of Defense for
Acquisition. 

The IG found, however, that the University's inventory of commercial
activities included data on activities such as medical and dental
equipment; research and development support; data processing
services; training support; and the maintenance, repair and
alteration of real property, but excluded other functions such as
printing and reproduction, audiovisual, and library services. 
Further, the University did not have a special program office to
ensure that the program was carried out. 

In response to the IG's finding, the University implemented
commercial activities program procedures and contacted the A-76
representative for the National Naval Medical Center to coordinate
all program matters.  The University updated its inventory of
commercial functions and added printing and reproduction,
audiovisual, and library services.  In compliance with DOD
instructions, the commercial activities inventory report has been
submitted to the Assistant Secretary of Defense, Production and
Logistics.  The report included a schedule for cost analysis of those
functions subject to the program. 


   FINANCE
-------------------------------------------------------- Appendix IV:2

Three federal appropriations are the major sources of funding for the
University:  operation and maintenance; research, development,
testing, and evaluation; and procurement.  The University also
receives reimbursements for research projects in the form of grants
or contracts.  The IG's review found that the University did not have
an organizational master plan that describes the University's
methodology for achieving its mid- and long-range mission objectives
and requirements.  The purpose of such a master plan is to establish
a logical path toward accomplishing the mission, set mission
priorities, and provide reasonable justification for resources. 

The IG's review showed that the University's budget proposals were
generally straight-lined from one year to the next.  The only notable
changes were the effects of inflation.  Because no master plan
existed, University department heads independently determined the
requirements needed for their operations and projects and submitted
them to the financial management directorate.  The submissions were
approved by the Board and provided to DOD's Comptroller for inclusion
in the DOD budget. 

The IG's review also showed that the University had not validated
personnel requirements with DOD.  DOD requires its components to
manage, provide resources, and evaluate activities based on output
performance requirements and standards documented in performance
statements.  The University's 1989 budget request identified $24.8
million for civilian personnel or 67 percent of the University's
annual appropriated budget.  (Military personnel were included in the
respective service budgets.) No personnel baseline was identified
from which to establish resource requirements, nor could changes in
work load be tracked.  Personnel requirements were based on
comparisons with civilian medical schools or general functional
duties instead of performance requirements or work load analysis of
actual duties. 

The IG found that University funds are allocated based on judgments
of what programs were considered important at the moment rather than
on an established plan.  For example, the then University president
decided to divert funds to increase support to the Jackson Foundation
to prevent the financial ruin of the Foundation.  The IG found that
the amount of the diversion was not determined analytically based on
accurate cost data, and no complete, accurate analysis of the impact
of the transfer of funds was made. 

Other than quarterly meetings of the University Board, the IG found
no established budget review procedures.  The IG concluded that the
Board did not conduct in-depth reviews of mission performance or
budget execution.  The University had no systematic measurement of
progress to ensure that resources were being applied to mission
requirements, as requested in original budget proposals. 

Through a questionnaire distributed to its staff, the University
conducted a personnel study that was completed in January 1991, and
validated by an independent contractor.  The survey justified 867
civilians, 309 uniformed personnel, and 173 Jackson Foundation
employees to work in direct support of the University's mission.  A
Table of Distribution and Allowances was developed for each of 78
administrative work centers identified in the study and its
validation. 

The Board of Regents formed a Planning Committee to administer the
development of mid- and long-range master plans.  A strategic
planning group developed a strategic plan that was issued in December
1993, based on the results of accreditation self-studies.  This plan
is to be updated as conditions warrant. 

The University requested DOD approval of the College and University
Finance System as the University's accounting system.  The Defense
Finance and Accounting System reviewed the system in February 1992,
and approved its use for reporting purposes under the Federal
Managers Financial Integrity Act. 


   PERSONNEL MANAGEMENT
-------------------------------------------------------- Appendix IV:3

The Inspector General's report made seven recommendations dealing
with the University's personnel system.  These recommendations
covered issues involving (1) classification and position management,
(2) merit promotion, (3) equal employment opportunities, (4) training
programs, and (5) federal and state income tax. 


      CLASSIFICATION, POSITION
      MANAGEMENT, AND MERIT
      PROMOTION
------------------------------------------------------ Appendix IV:3.1

Federal personnel law requires that in determining the rate of basic
pay the principle of equal pay for substantially equal work be
followed.  The University published internal instructions to support
federal personnel law, directing each supervisor to certify the
accuracy of positions on a yearly basis and to prepare evaluation
statements for supervisory positions.  The IG's review found that the
University was not complying with either the intent of the federal
law or its own instructions.  For example, the IG's review included a
random sample of 50 position description and evaluation statement
documents and found that there was either no evaluation statement or
the documentation did not properly support the grade of supervisory
positions.  In two instances, an evaluation statement that supported
a lower grade was attached to a position description as supporting
documentation.  In 17 other instances there was no evaluation
statement for positions in a mixed general schedule grade series. 
Without evaluation statements, there was no rationale to explain how
the grade levels were determined. 

Seven of the 50 position descriptions that the IG examined had the
same duties and responsibilities but were classified at different
grade levels.  Through comparison of University positions with the
DOD Average Grade Statistics, the IG concluded that misclassification
of positions was a systemic problem at the University.  For example,
the University had two positions for GM-341, Administrative Officer,
classified at the GS-14 level that were comparable to the DOD average
grade level of GS-11 for the same position. 

The IG also found that the University had failed to support and
implement basic merit promotion procedures for filling positions. 
According to the IG, the practice of noncompetitive promotions was
commonplace at the University, with the following types of violations
identified: 

  adding duties to positions with known promotion potential and
     promoting the incumbent without competition,

  noncompetitive promotion from one job series into a different
     series,

  managers preselecting individuals for promotion by memorandum or
     notation on the personnel action form,

  reassignment of unqualified employees into key positions with
     promotion potential, and

  failure to properly document promotion actions. 

The Office of the Secretary of Defense and the Office of Management
and Budget conducted an evaluation of the University civilian
personnel program and, as a result, delegated the personnel
appointing and position classification authority to the Washington
Headquarters Service which developed a detailed plan of action for
correcting the deficiencies.  Data pertaining to alleged prohibited
personnel practices were collected by the University and the
Washington Headquarters Service.  The IG determined that the
University took appropriate actions, which included replacing the
president, vice-president of operations, and civilian personnel
officer.  A 100-percent position reclassification or restructuring
was conducted, which resulted in savings of about $200,000. 

The University implemented internal control procedures and
established standard operating procedures for civilian resource
management.  The University also established instructions for the
completion and approval of requests for personnel actions and for the
merit promotion and placement program . 


      EQUAL EMPLOYMENT
      OPPORTUNITIES
------------------------------------------------------ Appendix IV:3.2

The IG identified three equal employment opportunity (EEO) violations
at the University: 

  the EEO responsibilities were not included in position descriptions
     of individuals assigned EEO responsibilities;

  of 80 University supervisors, 25 did not have EEO has a critical
     element in their performance standards; and

  pictures of EEO representatives were not displayed on any public
     bulletin board. 

EEO responsibilities were incorporated in all appropriate position
descriptions when classification audits were done as part of the
100-percent reclassification review.  An Equal Employment Officer
began work in July 1991, and a University EEO instruction was
implemented in May 1993. 


      TRAINING PROGRAM
------------------------------------------------------ Appendix IV:3.3

In its review of the chief personnel officer's activities, the IG
found a lack of oversight and improper management of the University's
training program.  Employees did not receive the training required to
satisfactorily perform their jobs, such as mandatory training for
contracting officers.  Supervisors and managers were not fulfilling
their obligations to manage training dollars and improve the
management of staff resources. 

An experienced employee development specialist was appointed in
August 1991 and was charged with developing a functional program to
meet or exceed legal and regulatory requirements.  The University now
requires an individual development plan for all employees in formal
training programs.  All others must be supported by an individual
development plan or a written department or office training plan. 


      FEDERAL AND STATE INCOME TAX
------------------------------------------------------ Appendix IV:3.4

The IG found that the University had not established procedures to
ensure the collection of federal and state income taxes from foreign
exchange students and recommended that the University review all
records pertaining to the Exchange-Visitor program to correct tax
withholding discrepancies.  The IG also recommended that the
University develop written procedures and policies to ensure
administrative controls and oversight of the program. 

A University standard operating procedure was finalized in February
1990.  All affected employees who were on board at the time of the
IG's review were contacted and all required tax forms were completed. 


   ACQUISITION
-------------------------------------------------------- Appendix IV:4

The IG focused its review on issues relating to the University's
implementation of standard DOD logistics support methods and
compliance with the Federal Acquisition Regulations and the Defense
Federal Acquisition Regulation Supplement.  The IG made nine
recommendations involving six issues:  (1) contracting and auditing
procedures, (2) logistical support, (3) property management and
accountability, (4) controlled items and substances, (5) records
management, and (6) cafeteria operations. 


      CONTRACTING AND AUDITING
      PROCEDURES
------------------------------------------------------ Appendix IV:4.1

The IG found that the University was awarding contracts without field
pricing.  The purpose of field pricing is to give the contracting
officer a detailed analysis of a proposal for use in contract
negotiations, such as providing the basis for price determination. 
For example, an $8.9 million contract was awarded on the last day of
fiscal year 1988 but the contract proposal was not received until
November of 1988.  The contract amount on the proposal was $8.8
million.  According to the IG, this contract was awarded on the basis
of available funds rather than on contracting principles. 

Another purpose for field pricing is to establish indirect cost rates
for the negotiation process.  Without field pricing, the contracting
officer had to rely on previous indirect cost rates that were based
on a lower volume of sales by the contractor (the higher the sales
volume, the lower the indirect cost rate for a particular contract). 
The IG found that field pricing may have saved the University over
$200,000 on the $8.9 million contract. 

Under the Office of Management and Budget guidelines for nonprofit
organizations doing business with federal agencies, the agency with
the largest dollar value of awards will be the cognizant audit agency
for the negotiation and approval of indirect cost rates.  The
assignment will not be changed unless there is a major long-term
shift in the dollar volume of the federal awards to the organization. 
At the time of the IG's review, the cognizant audit agency for the
Jackson Foundation was the Department of Health and Human Services. 
However, a 1989 award from DOD had resulted in a major long-term
shift in the dollar volume of Jackson awards from the Department of
Health and Human Services to DOD.  According to the IG, the
University should have requested that DOD assume audit responsibility
for the Jackson Foundation but had not made such a request to DOD. 

Since June 1990, the Contracting Division has experienced 100-
percent turnover in personnel.  All new contract division personnel
have been made aware of the requirements of the Federal Acquisition
Regulations, with respect to field pricing support.  The Contracts
Division has implemented DOD procedures for documenting contract
negotiations for awards exceeding $100,000.  Contracts division
personnel have received mandatory training funded through the DOD
Acquisition Enhancement program. 

Upon urging from the University, the Defense Contract Audit Agency
agreed to assume audit responsibility for the Jackson Foundation.  In
1991, the Defense Contract Audit Agency informed the Jackson
Foundation that it had full audit cognizance for contracts for fiscal
year 1989 and forward. 


      LOGISTICS SUPPORT
------------------------------------------------------ Appendix IV:4.2

According to the IG, the University had failed to use the Defense
Asynchronous Message Entry System for its procurements, which
resulted in duplicated efforts in the requisition process.  The
System permits the University to submit machine-processible
requisitions to the Defense Automated Addressing System Office, which
then transmits the requisitions to the appropriate federal supply
source.  Instead, the University relied on a manual system to
requisition items stocked by the Defense Logistics Agency or the
General Services Administration.  The requisitions were mailed to
those activities, where they were input into automated logistics
systems.  According to the IG, if the University had used the Defense
Asynchronous Message Entry System only one transaction would have
been needed, and the margin of error would have decreased because of
built-in quality checks. 

In November 1989, the Defense Asynchronous Message Entry System was
fully implemented by the University and is being used for placing all
Defense Logistics Agency and General Services Administration orders,
as well as receiving on-line status of requisitions. 


      PROPERTY MANAGEMENT AND
      ACCOUNTABILITY
------------------------------------------------------ Appendix IV:4.3

The University's Logistics Division was responsible for administering
and directing the property management program.  The program includes
warehousing of all equipment and furniture assigned to the University
and receiving, identifying, delivering, and controlling all property
entering or leaving the University.  The IG found that the University
did not use effective warehousing practices.  Property was stored in
a parking garage and was vulnerable to waste, loss, unauthorized use,
damage, and theft.  Property stored in this area was secured by a
ceiling to floor chain-link fence with two entries locked with
standard padlocks. 

In March 1989, an inventory of the University property identified
about $471,000 worth of property that was unaccounted for or lost. 
The University's vice-president of operations directed that all
property items valued at less than $500 and not accounted for be
deleted from the records without further investigation.  This
property was valued at about $138,000. 

A new storage building was built and all accountable property moved
into it.  The University has issued personal property reporting and
disposal procedures and developed an 83-element property management
checklist.  The University also developed a property custodian guide
and procedures for accounting for lost, damaged, or destroyed
property.  All property custodians were trained by January 1992. 
During biannual inventories, all property custodians are briefed
before beginning their inventory and new custodians are given a
property custodian briefing. 


      CONTROLLED ITEMS AND
      SUBSTANCES
------------------------------------------------------ Appendix IV:4.4

The University pharmacy is located in the Department of Laboratory
Animal Medicine and is responsible for the procurement and management
of controlled and noncontrolled pharmaceutical items required to
support the University's teaching and research mission.  The IG found
that the University violated security requirements for controlled
items, promulgated by DOD.  One of the basic security measures
required is a limited access area defined by a barrier extending from
floor to ceiling.  Hypodermic syringes and needles were stored on
shelves and carts in the back of the self-service store.  All
employees of the store had access to the storage area. 

The University supplements the DOD directives with standard operating
procedures including detailed security procedures for the pharmacy
safe.  The IG found however that, with few exceptions, the security
procedures were not followed during a test period.  Further, in 19
instances the same person initialed opening, closing, and checking
the safe. 

More specifically, the IG found that the pharmacy officer did not
maintain a complete and accurate inventory of all controlled
substances as required by University regulation.  Further, the IG
stated that the University's failure to adhere to established
controls over the inventory resulted in inaccurate inventory
balances, loss of accountability, over- or underprocurement of
supplies, and the opportunity for theft or misuse. 

In June 1991, the University issued procedures that implement
previous University and DOD instructions and federal regulations. 
Also, unannounced reviews are made at least three times a month to
ensure that logs to record opening and closing of the pharmacy safe
are completed and that departments receive monthly controlled
substance reports. 


      RECORDS MANAGEMENT
------------------------------------------------------ Appendix IV:4.5

DOD has established a records management program that identifies
responsibility for the life cycle management of records from creation
through maintenance, use, and disposition.  The IG found that the
University had no procedures for a centralized records management
system:  each office kept its inactive files either with current
files or in storage areas that had not been designated as records
holding areas.  In areas inspected, there were boxes of records that
were undated, not labeled, and opened with files in disarray; boxes
were thrown together and haphazardly stacked; and some had water
damage while others were crushed. 

The University has implemented the DOD Records Management Program and
used the Records Management Division, Washington Headquarters
Services, to train University personnel in records management. 
Training was completed in May 1991.  IG followup found that all
offices were in compliance with University procedures.  Schedules for
scientific, research, and educational records have been approved by
the National Archives. 


      CAFETERIA OPERATIONS
------------------------------------------------------ Appendix IV:4.6

The IG's review of University food service personnel records showed
that the employees did not have certificates or documentation to
indicate that they had received the required initial and refresher
training in food service sanitation principles.  Additionally, the IG
found that only 5 of 30 required bimonthly inspections had been
conducted by the University from October 1987 to June 1989. 

The IG requested to see the food handler cards of the cafeteria
employees; only 2 of the 11 employees could produce their cards. 
Further, 7 of the employees did not have physical examinations before
their initial assignment.  One of these employees had tested positive
for tuberculosis. 

All current employees have been issued food handler cards by the
Occupational Health/Preventive Medicine Department, National Naval
Medical Center, and all new employees are required to obtain food
handler cards.  All full-time employees also have completed food
service training sponsored by the Bureau of Medicine and Surgery. 


   INFORMATION RESOURCES
-------------------------------------------------------- Appendix IV:5

The information resources at the University consist of automated
information created and maintained for day-to-day operations and to
meet reporting requirements and information collected from and
disseminated to public sources.  The University Computer Center is
responsible for implementing life-cycle management controls,
approving hardware and software purchases, and maintaining an
accurate inventory and records of accountability. 

The IG found that the University had not followed DOD life-cycle
management procedures in the development, acquisition, and management
of automated data processing systems and resources.  Specifically,
the University did not complete the definition and design phase for
the automated financial system, the College and University Finance
and Accounting System.  The University had not defined the
performance factors necessary for the operation and assessment of the
financial system.  System objectives such as performance, size and
complexity of transactions, response times, types and formats of
reports, and internal controls were not documented.  Because the
University did not establish system objectives and performance
factors, it had no means to accurately evaluate the system's
efficiency, functional performance, and benefits to the organization. 

The IG found no written procedures to establish the University
Computer Center's responsibility for reviewing and approving all
automated data processing procurements.  The lack of written
procedures prevented enforcement of the University Computer Center's
responsibilities, which resulted in circumvention of the life-cycle
management process and unapproved purchases.  The University's
instructions covering automated information systems were reviewed and
found to provide adequate policy guidance for most life-cycle
management procedures.  This policy statement was rewritten in June
1993.  Internal policies have been implemented for the processing of
systems development and maintenance requests.  Acquisitions of all
automated data processing equipment and software are reviewed before
purchasing and small system decision papers are required for all
microcomputer purchases. 

An information resources management plan has been prepared with
5-year costs and alternatives for all projected information resources
management initiatives.  These initiatives have integrated the needs
of the departments with those of the University as a whole. 

The University established the Air Force Accounting System as the
baseline to evaluate the College and University Financial System for
efficiency, functional performance, and benefits to the organization. 
A Defense Finance and Accounting Service evaluation of the system
found that it is in compliance with GAO, Office of Management and
Budget, and DOD requirements.  In April 1992, procedures were
established and implemented in the College and University Financial
System to record all transactions associated with the Jackson
Foundation cooperative agreements. 


   LABORATORY AND ANIMAL MEDICINE
-------------------------------------------------------- Appendix IV:6

The Laboratory Animal Medicine Department provides the University
with animals for teaching and research, develops and implements
policy for care of the animals, and maintains a professional and
technical staff for veterinary medical care.  The IG found the
University's animal facilities extremely clean and well ventilated
and lighted.  However, the IG found some problems covering record
keeping, security, and protocol reviews. 


      ANIMAL RESEARCH RECORDS
------------------------------------------------------ Appendix IV:6.1

The IG found that animal records were not adequately maintained and
that there was no system for quality control.  The University has
issued directives that require documentation of all animal related
activity, including information on the general condition of the
animals.  The purpose of this information is to provide a history of
teaching and research projects and documented evidence to validate
the outcome of the projects.  The IG also found a breakdown in
management controls over recording transactions for controlled
substances.  Controlled substances are used as anesthetic agents to
prevent pain and suffering of the animals during animal surgery and
research analysis. 

Corrective actions and a quality control system have been implemented
to ensure cage or animal numbers are included on the records. 
Procedures have been implemented to ensure copies of the anesthesia
records are filed in the appropriate animal's health record.  A
quality assurance system for animal records, consisting of an 89-item
record audit checklist and 8 to 10 audits per month, has been
implemented. 


      LABORATORY SECURITY
------------------------------------------------------ Appendix IV:6.2

The security of the facilities housing the animals that the
University uses in teaching and research programs is paramount to the
safety of the animals and the integrity of the research programs. 
The University's security system consists of a number of locked doors
that can only be opened by access cards.  The cards are programmed to
allow entry only into certain areas and only during certain hours. 

The IG found that 37 percent more cards had been issued than needed
for the number of people conducting research with animals.  The
University did not have written guidelines for issuing the cards or
an accurate inventory of the access cards. 

The University developed written instructions that were issued to
each individual when they were issued an access card.  A random
spot-check of card holders entering the animal facility is conducted,
then cross-referenced against the issued card inventory.  Should a
discrepancy be noted, it is investigated and resolved by the central
animal facility security officer.  All excess cards that have not
been issued are stored in a combination safe with a current inventory
list. 


      ANIMAL REVIEW BOARD
------------------------------------------------------ Appendix IV:6.3

The University established the Laboratory Animal Review Board to
carry out DOD requirements.  The board reviews research and teaching
protocols using animals, recommends approval or disapproval, and
conducts periodic inspections of animal facilities.  The IG found
that the review board had inadequately managed animal research
protocol reviews. 

The review board used a research protocol review request log to keep
track of the review and approval process.  An IG comparison of the
log with the original research proposal showed that in 50 percent of
the cases examined the original proposal document did not have a
signature to match the reviewer shown on the log.  Also, the IG found
that none of the original research documents examined was reviewed by
all nine review board members; at most four members had signed as
reviewers.  In one instance, the chairman of the board was the
originator of the proposal and was the only member to approve the
protocol. 

Procedures have been instituted requiring reviewers to submit signed
review sheets with their comments recommending approval or
disapproval.  The final decision on proposals will be determined by a
quorum of members at the review committee meeting, and the chairman
will not be the signing authority for proposals on which he or she is
the principal or participating investigator. 

