United States Government Accountability Office

GAO Report to the Committee on Health, 

Education, Labor, and Pensions, U.S. 

Senate 

MILITARY BASE 

REALIGNMENTS 

AND CLOSURES 

Impact of 

Terminating, 

Relocating, or 

Outsourcing the 

Services of the Armed 

Forces Institute of 

Pathology 

November 2007 

 

GAO-08-20 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

November 2007

MILITARY BASE REALIGNMENTS AND 

CLOSURES 

Impact of Terminating, Relocating, or Outsourcing the 

Services of the Armed Forces Institute of Pathology Highlights of GAO-08-20, a report to the 

Committee on Health, Education, Labor, 

and Pensions, U.S. Senate 

The 2005 Base Realignment and 

Closure (BRAC) provision required 

the Department of Defense (DOD)

to close the Armed Forces Institute 

of Pathology (AFIP). GAO was 

asked to address the status and

potential impact of implementing 

this BRAC provision. This report 

discusses (1) key services AFIP 

provides to the military and civilian 

communities; (2) DOD’s plans to 

terminate, relocate, or outsource 

services currently provided by

AFIP; and (3) the potential impacts

of disestablishing AFIP on military 

and civilian communities. New 

legislation requires DOD to

consider this GAO report as it 

develops its plan for the 

reorganization of AFIP. GAO 

reviewed DOD’s plans, analysis, 

and other relevant information, and 

interviewed officials from the 

public and private sectors. 

What GAO Recommends

GAO recommends DOD report to 

Congress on (1) its strategies for 

organizing consultation services; 

(2) the repository’s assets and their 

potential use; and (3) its strategies 

for using the repository. DOD 

generally concurred with GAO’s 

findings and conclusions. GAO has 

modified its recommendations to 

reflect concerns DOD raised about 

additional steps it needs to take 

before it can report on its strategies 

for using the repository. VA stated 

that GAO’s report was factually

accurate, but believed that it did 

not sufficiently describe the impact 

of closing AFIP. GAO believes that 

this report provides a balanced 

assessment of AFIP’s services and 

the impact of its closing.

AFIP pathologists perform three key services—diagnostic consultations, 

education, and research—primarily for physicians from DOD, the Department 

of Veterans Affairs (VA), and civilian institutions. AFIP provides consultations 

when physicians cannot make a diagnosis or are unsure of their initial 

diagnosis. About half of its 40,000 consultations in 2006 were for DOD 

physicians, and the rest were nearly equally divided between VA and civilian 

physicians. AFIP’s educational services train physicians in diagnosing the 

most difficult-to-diagnose diseases. Civilian physicians use these services 

more extensively than military physicians. In addition, AFIP pathologists 

collaborate with others on research applicable to military operations and 

general medicine, often using material from AFIP’s repository of tissue 

specimens to gain a better understanding of disease diagnosis and treatment. 

To implement the 2005 BRAC provision, DOD plans to terminate most 

services currently provided by AFIP and is developing plans to relocate or 

outsource others. DOD plans to outsource some diagnostic consultations to 

the private sector through a newly established office and use its pathologists

for consultations when possible. With the exception of two courses, DOD 

does not plan to retain AFIP’s educational program. DOD also plans to halt 

AFIP’s research and realign the repository, which is AFIP’s primary research

resource. The BRAC provision allows DOD flexibility to retain services that 

were not specifically addressed in the provision. As a result, DOD will retain 

four additional AFIP services and is considering whether to retain six others. 

DOD had planned to begin implementation of the BRAC provision related to 

AFIP in July 2007 and complete action by September 2011, but statutory 

requirements prevent DOD from reorganizing or relocating AFIP functions 

until after DOD submits a detailed plan and timetable for the proposed 

implementation of these changes to congressional committees no later than 

December 31, 2007. Once the plan has been submitted, DOD can resume 

reorganizing and relocating AFIP. 

Discontinuing, relocating, or outsourcing AFIP services may have minimal 

impact on DOD, VA, and civilian communities because pathology services are 

available from alternate sources, but a smooth transition depends on DOD’s 

actions to address the challenges in developing new approaches to obtaining 

pathology expertise and managing the repository. For consultations, these 

challenges are to determine how to use existing pathology resources, obtain 

outside expertise, and ensure coordination and funding of services to avoid 

disincentives to quality care. While DOD has begun to identify the challenges, 

it has not developed strategies to address them. Similarly, whether the 

repository will continue to be a rich resource for military and civilian research

depends on how DOD populates, maintains, and provides access to it in the 

future, but DOD has not developed strategies to address these issues. DOD 

contracted for a study, due to be completed in October 2008, of the usefulness 

of the material in the repository. DOD plans to use this study to help make 

decisions about managing the repository. 

To view the full product, including the scope 

and methodology, click on GAO-08-20. 

For more information, contact Randall B. 

Williamson at (202) 512-7114 or 

williamsonr@gao.gov. 
Contents 

Letter 1

Results in Brief 3

Background 6

AFIP’s Key Services Include Consultation, Education, and 

Research That Benefit DOD, VA, and Civilian Communities 8 

DOD Has Specific Plans to Terminate Most Services Currently 

Provided by AFIP and Is Developing Plans to Relocate the 

Others 16

Closing AFIP May Have Minimal Effect, but Management Strategy 

Is Important to Address Key Challenges 23 

Conclusions 31

Recommendations for Executive Action 32 

Agency Comments and Our Evaluation 33 

Appendix I Scope and Methodology 37 

Appendix II Maps of the Armed Forces Institute of Pathology’s 

(AFIP) 2006 Consultations 39 

Appendix III Description of Services Performed by the Armed 

Forces Institute of Pathology (AFIP) 42 

Appendix IV Comments from the Department of Defense 46 

Appendix V Comments from the Department of Veterans Affairs 48 

Appendix VI GAO Contact and Staff Acknowledgments 51 

Related GAO Products 52 

Page i GAO-08-20 Armed Forces Institute of Pathology
Tables 

Table 1: Number and Percentage of AFIP Consultations for 

Customers, 2005 and 2006 10 

Table 2: Consultation Outcomes Where an Initial Diagnosis Was 

Provided, for 2006 11 

Table 3: Examples of AFIP’s Research Projects 15 

Table 4: Services Currently Performed by AFIP That Are to Be 

Retained and Relocated, or Established, or Are Awaiting 

Final Decisions 20 

Figures 

Figure 1: DOD’s Proposed Timeline for BRAC Implementation 

Pertaining to AFIP 22 

Figure 2: AFIP’s DOD Consultations for 2006 39 

Figure 3: AFIP’s VA Consultations for 2006 40 

Figure 4: AFIP’s Civilian Consultations for 2006 41 

Page ii GAO-08-20 Armed Forces Institute of Pathology 
Abbreviations 

AFIP Armed Forces Institute of Pathology 

ARP American Registry of Pathology 

ASD(HA) Assistant Secretary of Defense for Health Affairs 

BRAC Base Realignment and Closure 

CAP College of American Pathologists 

CDC Centers for Disease Control and Prevention 

CME continuing medical education 

DNA deoxyribonucleic acid 

DOD Department of Defense 

DU depleted uranium 

MTF military treatment facility 

PMO Program Management Office 

USUHS Uniformed Services University of the Health Sciences 

VA Department of Veterans Affairs 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 

Page iii GAO-08-20 Armed Forces Institute of Pathology 
United States Government Accountability Office

Washington, DC 20548 

November 9, 2007 

The Honorable Edward M. Kennedy 

Chairman 

The Honorable Michael B. Enzi 

Ranking Member 

Committee on Health, Education, Labor, 

 and Pensions 

United States Senate 

On May 13, 2005, the Department of Defense (DOD) recommended closing 

the Armed Forces Institute of Pathology1

 (AFIP)—an agency within 

DOD—as part of the Base Realignment and Closure (BRAC) process.2

 This 

would require that the pathology services currently provided by AFIP be 

discontinued, transferred to other parts of DOD or elsewhere, or 

outsourced to the civilian community. AFIP provides pathology 

expertise—which is based on laboratory analyses of tissue or other 

specimens to diagnose diseases or other medical conditions—to military 

and civilian physicians and maintains a rich and comprehensive catalog of

pathology material such as tissue specimens, referred to as the National 

Pathology Repository.3

 In addition to providing services to DOD, AFIP 

provides its expertise to other physicians such as those working at the 

Department of Veterans Affairs (VA) and it has statutory authority to 

 1

Pathology is the study of bodily changes due to disease, injury, or other medical 

conditions, and it can lead to advancements in diagnosis and treatment.

2

Through the BRAC process, DOD can recommend closing or realigning military facilities 

to reorganize its structure and facilitate new ways of doing business. These 

recommendations are reviewed by the independent BRAC Commission. The BRAC

Commission then issues its recommendations to the President. After the President 

approves the recommendations, they are forwarded to Congress, which has 45 days to

disapprove the recommendations on an all-or-none basis; if Congress does not act, the 

recommendations become binding. 

3

The National Pathology Repository, located at AFIP, stores material coded by pathologic 

diagnosis. The National Pathology Repository currently stores over 2.8 million cases coded 

since 1917. The material includes written records and over 50 million microscopic slides, 

30 million paraffin tissue blocks, and 12 million preserved wet tissue specimens. Cases 

represent the entire spectrum of human disease, including both sexes, all races/ethnicities, 

all ages, as well as animal disease, and come from contributors worldwide. Hereafter, the

National Pathology Repository is referred to as the repository. 

Page 1 GAO-08-20 Armed Forces Institute of Pathology
provide pathology services to civilian physicians.4

 According to the College

of American Pathologists (CAP) and other pathology organizations, AFIP 

is relied upon by its customers as a definitive consult on the most difficultto-diagnose cases and through its research and training has advanced the 

knowledge and competency of the medical profession. 

In accordance with the BRAC statute, DOD must complete closure and 

realignment actions within 6 years from the time the recommendations 

were forwarded to Congress, which for the 2005 BRAC provisions is 

September 15, 2011.5

 In light of the BRAC provision specific to AFIP,6 the 

Senate Committee on Health, Education, Labor, and Pensions requested 

an analysis of the impact of disestablishing, relocating, or outsourcing 

AFIP’s key services due to concerns that this would affect the ability of 

military and civilian communities to obtain high-quality pathology 

services. In this report, we discuss (1) the key services AFIP provides to 

the military and civilian communities; (2) DOD’s plans to terminate, 

relocate, or outsource services currently provided by AFIP; and (3) the 

potential impacts of disestablishing AFIP on military and civilian 

communities. 

To accomplish these objectives, we reviewed recent reports describing 

AFIP’s services and business practices, including a previous GAO report 

on AFIP’s business plan,7

 as well as those conducted by the Army Audit 

Agency and BearingPoint—a consulting company that fulfilled a contract 

from the Army Surgeon General to review AFIP. We also reviewed other 

documents and legislation pertaining to AFIP and the BRAC provision, 

including business plans and data related to analysis that led to BRACrelated decisions. Additionally, we obtained data from AFIP to describe 

key services it provides and we determined the data to be sufficiently 

reliable for the purposes of this report. We also interviewed officials from 

AFIP, VA, the American Registry of Pathology (ARP), and pathology 

associations such as CAP to collect information on the services that AFIP

 4

See 10 U.S.C. § 176(b)(1)(A). 

5

See Defense Base Closure and Realignment Act of 1990, Pub. L. No. 101-510, § 2904(a)(5), 

codified as amended at 10 U.S.C. § 2687, note. 

6

In this report, we refer to this as the BRAC provision. 

7

GAO, Armed Forces Institute of Pathology: Business Plan’s Implementation Is Unlikely

to Achieve Expected Financial Benefits and Could Reduce Civilian Role, GAO-05-615 

(Washington, D.C.: June 30, 2005). 

Page 2 GAO-08-20 Armed Forces Institute of Pathology
provides. Within DOD, we interviewed officials from the Offices of the 

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

Assistant Secretary of Defense for Health Affairs (ASD(HA)); the 

TRICARE Management Activity; the Office of the Deputy Under Secretary 

of Defense (Installations and Environment); the Uniformed Services 

University of the Health Sciences (USUHS)—a military medical training 

and research institution;8

 and the Office of the General Counsel. We also 

interviewed pathologists from DOD military treatment facilities (MTF) and 

VA medical centers. Finally, to assess the potential impacts of terminating 

AFIP and relocating services, we interviewed officials as mentioned above, 

civilian pathologists from major medical centers, as well as 

representatives from pathology and radiology associations such as ARP, 

CAP, the American Society for Investigative Pathology, the Association of 

Pathology Chairs, the American College of Radiology, and the Canadian

Association of Radiologists. We conducted our work from March 2007 

through November 2007 in accordance with generally accepted 

government auditing standards. Further details on our scope and 

methodology are described in appendix I. 

AFIP pathologists perform three key services—diagnostic consultations, 

education, and research—that benefit military and civilian communities. 

AFIP pathologists provide diagnostic consultations when physicians—that 

is, clinicians or general pathologists—at DOD, VA, or civilian medical 

centers cannot make a diagnosis or are unsure of their initial diagnosis. In

2006, AFIP provided over 40,000 diagnostic consultations, almost half of 

which were for DOD. AFIP’s remaining consultations were nearly equally 

divided between VA and civilian physicians. AFIP’s educational services 

include courses, texts, and distance learning activities that draw upon 

pathology material from the repository. AFIP’s educational services train 

physicians in diagnosing the most difficult-to-diagnose diseases. While 

DOD, VA, and civilian physicians use AFIP’s educational services, civilian 

physicians use AFIP’s educational services more extensively than military 

physicians. Regarding its research services, AFIP pathologists work 

individually and in partnership with other federal and private researchers 

using material from the repository to conduct research applicable to 

Results in Brief 

 8

USUHS consists of a military medical school and graduate nursing school and provides

doctoral and masters degrees in biomedical and public health. It is affiliated with major 

military teaching hospitals, such as Walter Reed Army Medical Center and Wilford Hall 

Medical Center. Additionally, USUHS is affiliated with the Washington Hospital Center, a

major civilian teaching hospital. 

Page 3 GAO-08-20 Armed Forces Institute of Pathology
military operations, as well as to diagnose and treat diseases affecting 

military and civilian health. For example, pathologists from AFIP were 

able to reconstruct the genome of the virus that caused the 1918 Spanish 

Flu pandemic from material in the repository. This discovery has provided 

a better understanding of how an avian flu epidemic can become deadly to 

humans, which in turn has affected current strategies to address the 

potential of pandemic flu. 

In accordance with the BRAC provision, DOD plans to terminate most 

services currently provided by AFIP and is developing plans to relocate or

outsource other services. Specifically, DOD plans to outsource its secondopinion and some initial consultations to the private sector through a new

Program Management Office (PMO), which was required to be established 

by the BRAC provision. DOD has not determined whether it would allow 

VA to obtain diagnostic consultations through the PMO. DOD plans to 

retain and relocate only two training programs currently offered by 

AFIP—the enlisted histology technician training and the DOD Veterinary 

Pathology Residency Program. DOD also plans to halt AFIP’s research and 

realign the repository, which is AFIP’s primary research resource. The 

BRAC provision provided DOD with flexibility to retain services that were 

not addressed in the provision. In accordance with this statutory authority, 

the ASD(HA) has retained four additional AFIP services and is considering 

whether to retain six others. DOD planned to begin implementation of the 

BRAC provision in July 2007 and to complete action by September 2011.

However, statutory requirements prevent DOD from reorganizing or 

relocating AFIP functions until after DOD has submitted detailed plans 

and timetables for the proposed reorganization and relocation to the 

House and Senate Appropriations and Armed Services Committees.9

 Once 

the plan has been submitted, DOD can resume reorganizing and relocating 

AFIP. However, other developments could impact the implementation of 

those plans. Specifically, Congress is considering requiring or allowing 

DOD to establish a new Joint Pathology Center. 

 9

See U.S. Troop Readiness, Veterans’ Care, Katrina Recovery and Iraq Accountability 

Appropriations Act, Pub. L. No. 110-28, § 3702, 121 Stat. 112, 144-45 (2007). This law

requires DOD to take into account this GAO report as it develops its detailed plan and 

timetable for the proposed reorganization and relocation of AFIP, if the GAO report is 

available on or before November 16, 2007. DOD is required to submit its plan no later than

December 31, 2007. 

Page 4 GAO-08-20 Armed Forces Institute of Pathology
Discontinuing or relocating AFIP services may have minimal impact on 

DOD, VA, and civilian communities because alternative services are 

available from other sources. Although AFIP is a noted center for 

pathology expertise, DOD, VA, and civilian pathologists may obtain 

pathology consultations from sources other than AFIP, as other medical 

institutions have subspecialty pathology experts that provide this service. 

Other institutions also provide pathology education and are used by DOD, 

VA, and civilian pathologists to fulfill continuing medical education (CME) 

requirements. Further, DOD, VA, and civilian pathologists could continue 

to conduct research, using material from the repository, and possibly 

through collaborations with other institutions. However, a smooth 

transition in services depends on DOD’s actions to address challenges 

involved in developing new approaches to obtain subspecialty pathology 

consultations and manage the repository to facilitate its use for research. 

For consultations, these challenges are to determine how to effectively use 

existing specialized pathology resources, obtain outside expertise, and 

ensure coordination and funding of services to encourage efficiency while 

avoiding disincentives to quality care. While DOD has begun to identify the 

challenges, it has not developed strategies to address them. Similarly, 

whether the repository will continue to be a rich resource for DOD, VA, 

and civilian research depends on how DOD populates, maintains, and 

provides access to it in the future, but DOD has not developed its 

strategies to address issues that will affect the viability and usefulness of 

the repository. DOD awarded a contract to study the usefulness of the 

material in the repository and will use the study, to be completed by the 

end of 2008, to help make decisions on how the repository will be 

managed. 

We are recommending that DOD include its strategies for organizing 

consultation services in its 2007 plan to Congress. Furthermore, we are 

recommending that DOD provide information on the status of the 

repository’s assets and their potential for research within 6 months of 

completing its study. We are also recommending that DOD provide a 

report to Congress, prior to USUHS assuming responsibility for the 

repository, on its implementation strategies for how it will populate, 

manage, and use the repository. 

In commenting on a draft of this report, DOD generally concurred with the 

findings and recommendations. However, our draft report had 

recommended that DOD provide information on its implementation 

strategies for how it will populate, manage, and use the repository within 

6 months of completing its study. DOD raised concerns with respect to 

steps it needs to take before it could report to Congress on its 

Page 5 GAO-08-20 Armed Forces Institute of Pathology
implementation strategies for how it will populate, manage, and use the 

repository. As a result, we altered our recommendations as described 

above. VA agreed that GAO’s report was factually accurate, but believed it 

did not sufficiently describe the impact of closing AFIP. We believe that 

we provided a balanced assessment of AFIP’s services and the impact of

its closing. 

In 1862, the Army Surgeon General established a repository in the Army 

Medical Museum for disease specimens collected from Civil War soldiers. 

The Army Institute of Pathology was created as a part of the museum in 

1944, using the museum’s extensive collection of disease specimens to 

develop expertise in diagnostic pathology. In 1949, the Army Institute of 

Pathology was renamed the Armed Forces Institute of Pathology, and the 

museum became a unit within AFIP. In 1976, the Department of Defense 

Appropriation Authorization Act for Fiscal Year 1977 established AFIP in 

its current form, as a joint entity of the Departments of the Army, Navy, 

and Air Force, to offer pathologic support to military and civilian medicine 

in consultation, education, and research.10

Throughout the early part of the 20th century, AFIP was the only 

institution in the country that maintained expertise in every major area of

anatomical pathology, attracting large numbers of consultations, trainees, 

and research grants on the basis of the institute’s unique reputation. 

However, according to AFIP’s Scientific Advisory Board, many changes in 

modern medical practice over the last several decades have altered the 

environment in which AFIP operates. For example, AFIP must now 

compete with over one hundred civilian medical institutions, many of 

which have in-house experts and comparable subspecialty areas of 

pathology. 

Background 

Role of AFIP 

AFIP provides pathology expertise for all branches of the military. AFIP 

also provides pathology expertise for VA in exchange for a specified 

number of VA staff positions assigned to AFIP. Additionally, AFIP offers 

pathology expertise on a reimbursable basis for its civilian customers. To

assist AFIP in this part of its mission, the Department of Defense 

Appropriation Authorization Act for Fiscal Year 1977 authorized ARP to be 

established as a nonprofit corporation with responsibility for encouraging 

 10See Pub. L. No. 94-361, § 811, 90 Stat. 923, 933-34 (codified at 10 U.S.C. § 176). 

Page 6 GAO-08-20 Armed Forces Institute of Pathology
and facilitating collaborative work between AFIP and civilian medicine.11

As such, ARP enters into contracts, collects fees, and accepts research 

grants on behalf of AFIP, in support of cooperative enterprises and 

interchange between military and civilian pathology. 

From 1998 through 2006, DOD and others conducted reviews that 

concluded that AFIP lacked controls over its financial operations, 

provided services for the civilian medical community without adequate 

reimbursement, and the costs of the services it provided to VA exceeded 

the value of the paid staff positions VA provided in exchange.12 These 

reviews concluded that DOD, in effect, subsidized AFIP’s work for VA and 

civilian customers. In response to these concerns, AFIP began making 

changes to its operations in 2000, including the development and 

implementation of a business plan meant to increase AFIP’s revenue and 

reduce DOD’s level of funding to AFIP. 

DOD Examines AFIP’s

Future Role 

DOD examined AFIP’s operations as part of the 2005 BRAC process, which

was intended to find ways to consolidate, realign, or find alternative uses 

for current facilities given the U.S. military’s limited resources. In making 

its 2005 BRAC recommendations, DOD applied statutory selection criteria 

that included military value, costs and savings, economic impact to local 

communities, community support infrastructure, and environmental 

impact.13 In applying these criteria, the law required that priority 

consideration be given to military value, and allowed the other criteria to 

be considered to a lesser extent. In DOD’s evaluation, AFIP received a low 

military value due to its large portion of civilian-related work. Therefore, 

DOD recommended disestablishing AFIP by relocating critical military 

services and terminating civilian-related activities currently provided by 

AFIP. 

 11Id. at 90 Stat. 934-36 (codified at 10 U.S.C. § 177). 

12From 1998 to 2002, AFIP was the subject of three program decision memorandums 

(documents used by DOD for planning and managerial oversight), four major DOD reviews,

and two DOD Inspector General reviews. 

13See Pub. L. No. 107-107, § 3002, 115 Stat. 1012, 1344-45 (2001) (codified at 10 U.S.C. § 

2687, note). This law authorized the 2005 BRAC round and revised some of the BRAC

procedures. The law also required DOD to publish its final selection criteria in the Federal 

Register, which DOD did in February 2004. See 69 Fed. Reg. 6948-52 (Feb. 12, 2004). 

Page 7 GAO-08-20 Armed Forces Institute of Pathology
As part of the BRAC process, the Secretary of Defense issued a report 

containing his realignment and closure recommendations, which were 

then reviewed by the BRAC Commission.14 The 2005 BRAC Commission’s 

final report contained recommendations to disestablish AFIP and relocate 

certain services that AFIP provides. These recommendations became 

binding as of November 9, 2005. In accordance with BRAC statutory 

authority, DOD must complete closure and realignment actions by 

September 15, 2011.15

AFIP pathologists perform diagnostic consultations, education, and 

research services benefiting DOD, VA, and civilian communities. In 2006, 

AFIP provided over 40,000 consultations, almost half of which were for 

DOD physicians. AFIP’s educational services include live courses, distance 

learning activities, and texts that draw upon pathology material from the 

repository with the goal of training physicians in diagnosing the most 

difficult-to-diagnose diseases. DOD, VA, and civilian physicians use AFIP’s 

educational services, but the civilian community uses AFIP’s educational 

services more extensively than military physicians. Regarding its research 

services, AFIP pathologists work individually and in partnership with 

other federal and private researchers using material from the repository to 

conduct research applicable to military operations as well as to diagnose 

and treat diseases affecting military and civilian health. 

AFIP’s primary mission is to provide diagnostic consultations. Its 

pathologists spend nearly twice as much time providing this service as 

they do providing education and research services. AFIP pathologists 

provide consultations for cases referred to them with and without 

diagnoses. That is, when physicians—clinicians or general pathologists—

at civilian, DOD, or VA medical centers cannot make a diagnosis or when 

they are unsure of their initial diagnosis and are in need of another 

AFIP’s Key Services 

Include Consultation, 

Education, and 

Research That Benefit 

DOD, VA, and Civilian 

Communities 

Providing Consultations Is 

AFIP’s Primary Mission, 

and DOD Is Its Most 

Frequent Customer 

 14The BRAC Commission is an independent body that has the authority to change the

Secretary’s recommendations if it determines that the Secretary deviated substantially 

from the selection criteria. See Pub. L. No. 101-510, § 2903 (codified as amended at 10

U.S.C. § 2687, note). The commission then makes recommendations to the President for 

approval or disapproval. After the President approves the recommendations, he transmits 

them to Congress. The recommendations become binding 45 legislative days after 

presidential transmission or at the adjournment of Congress, unless Congress enacts a joint 

resolution disapproving the recommendations.

15See Pub. L. No. 101-510, § 2904 (codified as amended at 10 U.S.C. § 2687, note). 

Page 8 GAO-08-20 Armed Forces Institute of Pathology
opinion, they can send the case to AFIP’s subspecialty pathologists16 for 

diagnostic consultation. According to the American Board of Pathology,

there are 10 different areas of subspecialty pathology, such as 

dermatopathology and forensic pathology. Additionally, pathologists are 

recognized as subspecialists in other areas of pathology pertaining to 

particular cancers, such as breast or prostate. Requesting physicians—

those who send cases to AFIP in search of diagnostic consultations—

typically need consultations for more complex cases that require the 

additional expertise of a subspecialty pathologist.17 In the course of 

providing these diagnostic consultations to the requesting physicians, 

AFIP receives and is able to add pathology material18 to its repository. As a 

result, consultations have been instrumental in expanding the repository. 

Over time, AFIP has increased the amount of services provided for DOD 

and decreased the amount of services provided for civilians. The total 

number of diagnostic consultations that AFIP provided remained relatively 

stable from 2000 to 2004. However, as we previously reported, DOD 

diagnostic consultations provided by AFIP increased by 30 percent from 

2000 through 2004, while its civilian consultations decreased by 

28 percent.19 We also reported that nearly all of the decrease in civilian 

consultations occurred in the 2 years after AFIP announced that it would 

raise its consultation fees beginning in January 2003. According to AFIP 

and civilian pathologists, this decrease in civilian diagnostic consultations 

was also attributed to a more competitive marketplace for obtaining 

consultations. Additionally, these pathologists also cited the loss of 

nationally recognized experts at AFIP as another possible reason for the 

decline in the number of civilian diagnostic consultations being sent to 

AFIP. 

 16Unlike general pathologists, subspecialty pathologists specialize in a particular organ

system and gain additional exposure, experience, and expertise in diseases and conditions

affecting the tissues of that system than general pathologists. 

17When AFIP receives a case for consultation, staff assign the case to the appropriate

subspecialty department based on the requesting physician’s indications. AFIP’s structure 

allows pathologists to consult with their colleagues who have expertise in different 

subspecialties as needed. 

18Pathology material includes paraffin blocks that enclose preserved tissue, gross tissue 

samples, microscopic glass slides, and clinical records such as X-rays and photographs. 

19GAO-05-615, 22-27. 

Page 9 GAO-08-20 Armed Forces Institute of Pathology
In 2006, AFIP provided almost half of its consultations to DOD physicians. 

From 2005 to 2006, AFIP decreased the total number of consultations it 

provided from 44,169 to 41,582. Consistent with earlier trends from 2000 to

2004, AFIP continued to increase the number and percentage of 

consultations provided to DOD and decrease the amount provided to the 

civilian community from 2005 to 2006. (See table 1.) In 2006, the largest 

percentage of consultations, approximately 48 percent, was conducted for 

DOD, followed by those for VA and civilian physicians at nearly 27 percent 

and 25 percent, respectively. AFIP also provided about 1 percent of its 

consultations for others, which included other federal agencies and 

foreign military services. While AFIP receives consultation requests from 

all over the world, consultations are heavily concentrated from more 

populous states and the East Coast. (See app. II for maps of AFIP’s 2006 

consultations.) 

Table 1: Number and Percentage of AFIP Consultations for Customers, 2005 and

2006 

2005 2006

Customer type Consultations

Percentage 

of total Consultations

Percentage

of totala

DODb19,464 44.1 19,856 47.8

VA 11,520 26.1 11,083 26.7

Civilian 12,708 28.8 10,287 24.7

Other federal agencies

c

456 1.0 334 0.8

Foreignd21 0.0 22 0.1

Total 44,169 100.0 41,582 100.0

Source: GAO analysis of DOD data. 

a

Does not add to 100 due to rounding. 

b

Includes the Army, Navy, and Air Force. 

c

Includes the Department of Health and Human Services, Department of Homeland Security, and 

others. 

d

Includes consultation requests from physicians from other countries, such as countries in Europe, 

Africa, or Asia. 

In 2006, about 62 percent (25,621) of AFIP’s cases were for consultations 

where AFIP pathologists reviewed the initial diagnoses from DOD, VA, 

civilian, or other physicians for confirmation or change. For these cases, 

AFIP pathologists changed the initial diagnoses from requesting physicians 

Page 10 GAO-08-20 Armed Forces Institute of Pathology
in 10,987 cases, or about 43 percent of the time. For the remaining 

57 percent of the cases (14,634), AFIP confirmed the requesting 

physicians’ initial diagnoses.20 When AFIP’s diagnoses differ from the 

requesting physicians’ initial diagnoses, it classifies the changes as either 

minor or major. According to AFIP, a minor change often involves a 

change in severity of the condition diagnosed or the choice of appropriate 

therapy. For example, the initial diagnosis may have correctly identified a 

tumor as malignant but may have assigned an incorrect type or level of 

aggressiveness, which could affect treatment and prognosis. In addition, 

AFIP classifies a change as major if it involves a change in the nature of 

the condition diagnosed. For example, a major change would include 

changing a diagnosis from malignant to benign. Both minor and major 

diagnosis changes can lead to a different treatment and, ultimately, a 

different outcome for the patient. As shown in table 2, most of AFIP’s 

changes to initial diagnoses that were provided by requesting physicians 

were classified by AFIP as minor changes. 

Table 2: Consultation Outcomes Where an Initial Diagnosis Was Provided, for 2006 

Outcome Consultations Percentage of total

a

Initial diagnosis confirmed 14,634 57.1

Minor changeb10,116 39.4

Major changeb871 3.4

Total 25,621 100.0

Source: GAO analysis of DOD data. 

a

Does not add to 100 due to rounding. 

b

Minor and major changes were classified as such by AFIP. 

The type of consultations DOD, VA, and civilian physicians seek from 

AFIP differ somewhat, both in terms of the number of cases sent without a 

diagnoses and the type of pathology expertise requested. For example, 

47 percent of DOD’s consultation requests were sent without an initial 

diagnosis, compared to 27 percent from VA and 31 percent from civilian 

physicians. This may be due, in part, to the type of expertise DOD and 

civilian physicians most commonly need, which also differs. For example, 

in 2006, almost a quarter of all DOD consultations were in the area of

 20According to AFIP pathologists, confirmation of an initial diagnosis is important because 

physicians seeking a consultation generally do not begin treating a patient until another 

pathologist confirms that the initial diagnosis is correct. 

Page 11 GAO-08-20 Armed Forces Institute of Pathology
forensic toxicology, which includes examining material from autopsies 

and testing biological specimens for alcohol and drugs. However, VA 

physicians most frequently requested AFIP’s environmental toxicology 

diagnostic consultations, while civilian physicians most frequently 

requested hepatic consultations—involving diseases of the liver—as well 

as gastrointestinal consultations. The other consultation service most 

frequently requested by DOD, VA, and civilian pathologists was for 

dermatopathology—or the interpretation of skin biopsies. 

AFIP Provides Varied 

Educational Services, Used 

Primarily by Civilian 

Physicians 

AFIP, in conjunction with ARP, offers a variety of courses, conferences, 

and other educational services, generally for physicians, and tailors its 

curriculum to the most common as well as the most difficult-to-diagnose 

diseases. AFIP staff design and conduct live and distance learning courses 

that aid physicians in expanding their medical knowledge as well as 

fulfilling their state licensure requirements for CME credit. AFIP’s 

educational services cover a range of topics in the fields of pathology,

radiology, and veterinary pathology, with particular emphasis on 

identifying emerging diseases, offering new insights into known diseases, 

and giving hands-on experience in diagnosing difficult cases. In developing

material for conferences, courses, and texts, AFIP staff query a database 

of recent consultations searching for the most common missed 

diagnoses—that is, those cases in which the requesting physician 

misdiagnosed the case, as well as diagnoses in which the requesting 

physician most frequently did not make an initial diagnosis. 

In 2006, AFIP, in conjunction with ARP, offered 28 formal courses, 24 

video teleconferences, and 4 Web-based courses. These courses qualify for 

CME credit, which assists DOD, VA, and civilian pathologists and other 

physicians in fulfilling state requirements for maintaining their medical 

licenses.21 Civilian physicians use AFIP’s training services more 

extensively than DOD and VA physicians. In 2006, 61 percent of the 

students attending AFIP’s CME courses were civilians, 34 percent were 

DOD attendees,22 and 5 percent were from VA. Most live CME courses are 

attended predominantly by civilians. For example, in 2006, 96 percent of 

 21In 2006, AFIP offered six courses, including the Radiologic-Pathologic Correlation course,

targeted to medical residents. Practicing physicians are permitted to attend any of AFIP’s 

courses for residents and may earn CME credit for attendance. 

22DOD attendees include both active duty military personnel and physicians employed by 

DOD as federal government employees. 

Page 12 GAO-08-20 Armed Forces Institute of Pathology
the residents who attended the Radiologic-Pathologic Correlation course 

were civilians. However, some courses are solely attended by military 

health professionals because they involve issues specific to DOD or 

because AFIP does not allow civilians to attend classes such as its Air 

Force Medical Forensic Sustainment course. Overall, AFIP’s courses have 

attracted instructors and students from around the world. In 2006, 

individuals representing over 70 institutions, including the Federal Bureau 

of Investigation, the National Institutes of Health, private academic 

institutions and medical centers, and MTFs participated in AFIP’s CME 

program. 

According to military pathologists, AFIP’s distance learning programs are 

a convenient and economical way to obtain CME requirements and fulfill 

state licensure requirements. AFIP’s distance learning programs include 

AskAFIP, an online database maintained and operated by AFIP. To hone 

diagnostic skills, AskAFIP allows users to query a database that contains

information from AFIP’s collection of specific diagnoses, texts, case 

materials, and images from the repository. DOD, VA, and civilian 

physicians have access to AskAFIP. Also, as part of its distance learning 

educational services, AFIP’s pathologists review diagnoses provided by VA

pathologists—known as the Systematic External Review of Surgicals 

program.23

In addition to offering courses, in conjunction with ARP, AFIP publishes 

examples of clinical-pathologic correlations, which describe the 

relationships that exist between the clinical symptoms or attributes 

exhibited by a patient and the pathological abnormalities of a specific 

disease or type of tumor. These correlations are published in texts called 

fascicles,24 which DOD, VA, and civilian pathologists told us are a primary 

reference source and serve as an important, frequently used tool as they 

 23Unlike the consultation process, the Systematic External Review of Surgicals program is a 

peer review or quality assurance process. VA policy requires its pathologists to submit 

cases—in which the VA pathologist already rendered a diagnosis—to AFIP. Then, AFIP

subspecialty pathologists review the rendered diagnosis for quality review purposes and

provide feedback to the pathologist who submitted the case in an effort to improve the 

practice of pathology. 

24ARP holds the copyright for these fascicles.

Page 13 GAO-08-20 Armed Forces Institute of Pathology
practice pathology.25 The fascicles are updated to capture the more recent 

developments in pathology. 

AFIP’s Research Benefits 

DOD, VA, and Civilians 

The combination of unique case material and expertise of AFIP 

pathologists facilitates AFIP’s research that benefits DOD, VA, and civilian 

medicine and results in hundreds of publications each year. Research is 

conducted by AFIP pathologists, as well as by other federal and private 

researchers in collaboration with AFIP pathologists, primarily using 

material from the repository.26 All outside researchers are required to 

collaborate with an AFIP pathologist in order to access AFIP’s materials. 

The repository contains over 3 million disease specimens and their 

accompanying case histories dating back over 150 years. Because of the 

large volume of cases in the repository, researchers can conduct studies of 

considerable sample size. Since AFIP receives pathology material for many 

difficult-to-diagnose diseases, the repository contains complex and 

uncommon cases that have accumulated over time. Studying these 

samples allows for advances in diagnosis and treatment of diseases. For 

example, AFIP has accumulated a large collection of gastrointestinal 

stromal tumors, a relatively uncommon tumor. Recent studies involving 

this collection have led to advances in the identification of, and therapy 

for, this tumor. One of the responsibilities of AFIP pathologists is to 

classify the material that AFIP receives into the repository so that 

researchers can access it in the future. As medical knowledge evolves, 

AFIP pathologists reclassify material in the repository to better 

characterize it for future use. AFIP staff are also in the process of putting 

material from the repository in digital form to expand its use for research. 

AFIP conducts and collaborates on research applicable to military 

operations and general medicine, so its research affects DOD, VA, and 

civilian communities. Although “militarily relevant” research has not been 

well-defined, AFIP staff said it generally includes subjects of direct 

interest to the military. For example, according to AFIP staff, research 

 25There are different types of fascicles, for example Tumors of the Kidney, Bladder, and

Related Urinary Structures and Non-Neoplastic Disorders of the Lower Respiratory

Tract. 

26AFIP also maintains, in conjunction with ARP, over 30 international registries, such as

Depleted Uranium, Agent Orange, and tumor registries. A comprehensive database of 

disease diagnoses and patient demographic data, incorporating all cases ever reviewed at

AFIP, is available to researchers. 

Page 14 GAO-08-20 Armed Forces Institute of Pathology
conducted in collaboration with the Armed Forces Medical Examiner has 

led to developments such as improved body armor and acute care of 

wounded personnel. Further, AFIP conducts and collaborates on 

infectious disease and cancer research, which has applicability for the 

civilian community as well. AFIP’s infectious disease research has focused 

on the characterization of potentially epidemic organisms, such as severe 

acute respiratory syndrome, as well as on the development of improved 

vaccines and the detection of biologic toxins, such as those that may be 

used in biological warfare. AFIP’s cancer research, including breast, 

gynecologic, and prostate cancers, has resulted in more accurate diagnosis 

and development of better treatment methods. Table 3 provides examples 

of AFIP’s research projects, including their impact. 

Table 3: Examples of AFIP’s Research Projects 

Research project Description

Body armor AFIP conducted a study examining full autopsies on U.S. troops killed in Iraq and Afghanistan from March 

2003 to mid-2005. Investigators found that 80 percent of the fatalities could have been prevented by better 

protection for the shoulder, back, chest, and side areas. As a result, DOD decided to redesign body armor. 

Thoracic needle AFIP conducted a study examining why field medics’ procedures to treat collapsed lungs were not working. 

Researchers discovered that a soldier’s muscle thickness is greater than the average person’s muscle

thickness. As a result, DOD now uses thicker, longer needles to penetrate the lung. 

Spanish influenza The 1918 influenza pandemic killed more than 50 million people worldwide. AFIP pathologists were able to 

decode the genetic sequence of the 1918 strain by examining tissue samples in the repository from World 

War I soldiers who had died of the disease in 1918. Understanding the genetic sequence of this influenza 

virus could aid in predicting future influenza pandemics and in developing interventions and treatment of 

virulent influenza viruses. 

Reye syndrome Reye syndrome primarily affects children, causing sudden brain damage and liver function problems. AFIP 

pathologists found that Reye Syndrome was associated with the use of aspirin to treat chickenpox or upper 

respiratory infection in children. As a result of understanding this association, the Food and Drug

Administration issued a package insert for aspirin warning against prescribing aspirin to infants and children 

with chickenpox or flu. There has been a sharp decline in the number of infants and children with Reye

Syndrome since this discovery, and it is now very rare. 

Source: GAO analysis of DOD data. 

The research conducted at AFIP results in hundreds of publications per 

year, but it has been declining. For example, in 2005 researchers at AFIP 

published 174 peer-reviewed articles and 121 abstracts, and in 2006 

researchers at AFIP published 145 peer-reviewed articles and 73 abstracts.

In a previous GAO report, we found that from 2000 through 2004, the 

number of research protocols at AFIP declined from 371 to 296.

27 AFIP 

 27See GAO-05-615. A research protocol is a detailed proposal, approved by AFIP’s research 

committee, which describes the research that will be completed. 

Page 15 GAO-08-20 Armed Forces Institute of Pathology
staff said that they began to focus on increasing militarily relevant 

research and reducing DOD-funded civilian-focus research as early as 

2001. 

The 2005 BRAC provision specifies that AFIP be disestablished. 

Accordingly, most services currently provided by AFIP will be terminated 

and other services will be relocated or outsourced. Specifically: 

• DOD plans to outsource second-opinion consultations and some initial 

diagnostic consultations to the private sector through a newly established 

PMO. 

• With the exception of two educational courses, DOD does not plan to 

retain and relocate the educational programs currently offered by AFIP. 

• DOD plans to halt AFIP’s research and realign the repository, which is 

AFIP’s primary research resource, to the Forest Glen Annex, Maryland, 

under the management of USUHS. 

The BRAC provision allows DOD the flexibility to retain capabilities that 

were not specifically addressed in the provision. In accordance with this

statutory authority, the ASD(HA) has retained four additional AFIP 

services and is considering whether to retain six others. According to 

DOD’s most recently developed implementation plan, dated February 

2007, DOD had planned to begin implementation of the BRAC provision 

relating to AFIP in July 2007 and to complete action by September 2011. 

However, a provision from the 2007 supplemental appropriations act 

prevents DOD from reorganizing or relocating any AFIP functions until 

after DOD has submitted detailed plans and timetables for the proposed 

reorganization and relocation to Congress.28 Once the reorganization plan 

has been submitted, DOD can resume reorganizing and relocating AFIP. 

DOD plans to terminate AFIP’s provision of diagnostic consultations and 

outsource certain DOD diagnostic consultations to the private sector 

through a newly established PMO. More specifically, the BRAC provision 

DOD Has Specific 

Plans to Terminate 

Most Services 

Currently Provided 

by AFIP and Is 

Developing Plans to 

Relocate the Others 

Most of AFIP’s Services 

Will Be Terminated, but 

Some Will Be Relocated 

 28Section 3702 of the appropriations act requires DOD to take into account this GAO report 

as it develops its detailed plan and timetable for the proposed reorganization and 

relocation of AFIP, if this GAO report is available on or before November 16, 2007. This 

effectively suspends the disestablishment and relocation of AFIP services until DOD 

submits its plan to Congress; the deadline for submission is December 31, 2007. 

Page 16 GAO-08-20 Armed Forces Institute of Pathology
requires that the PMO be established at the new Walter Reed National 

Military Medical Center in Bethesda, Maryland,29 to coordinate pathology 

results, contract administration, quality assurance, and control of DOD 

second-opinion consults worldwide. DOD plans to relocate sufficient 

personnel from AFIP to the new PMO to conduct its activities.30 Further, 

DOD’s justification for this provision states that DOD will also rely on the 

civilian market for providing initial diagnoses when the local pathology 

labs’ capabilities are exceeded. 

In determining the legal implications of the BRAC provision with respect 

to consultation services, DOD’s Office of General Counsel concluded that 

military second-opinion consultations as currently provided by AFIP 

would not be subject for retention because the PMO would be required to

outsource these consultations. Initial diagnoses would either be provided 

by military pathologists or possibly military subspecialty pathologists at 

MTFs when possible or outsourced through the PMO. Although the PMO 

would not coordinate civilian diagnostic consultations, DOD has not 

determined whether it would allow VA or other federal agencies to obtain 

diagnostic consultations—either initial or second-opinion—through the 

PMO. The PMO working group, including DOD and VA officials, met in 

August 2007 to discuss the establishment of the PMO. 

Regarding the retention of educational services, DOD does not plan to 

relocate any educational services currently offered by AFIP with the 

exception of the enlisted histology technician training and the DOD 

Veterinary Pathology Residency Program. The BRAC provision requires 

DOD to relocate the enlisted histology technician training to Fort Sam 

Houston, Texas. The DOD Veterinary Pathology Residency Program would 

be relocated to Forest Glen Annex, Maryland. 

With respect to the research, DOD plans to realign the repository, which is 

AFIP’s primary research resource, to Forest Glen Annex, Maryland, to be

managed by USUHS. USUHS issued a Request for Proposal in May 2007, 

for the purpose of contracting for a review of the quality of the pathology 

 29The BRAC Commission recommended that DOD realign Walter Reed Army Medical 

Center, Washington, D.C., as follows: relocate all tertiary (subspecialty and complex care) 

medical services to National Naval Medical Center, Bethesda, Maryland, establishing it as

the new Walter Reed National Military Medical Center, Bethesda, Maryland. 

30Emphasis would be placed on preserving AFIP consultation services to military and other 

federal customers until the PMO is operational, with earlier disestablishment of AFIP 

research and education activities. 

Page 17 GAO-08-20 Armed Forces Institute of Pathology
material and associated case records contained in the repository. USUHS 

officials told us that they will make further decisions regarding laboratory 

and storage facility requirements for the repository, as well as plans for 

staffing and research uses, when the evaluation is complete. Pending the

outcome of this review, USUHS may employ 10-12 pathologists who would 

spend the majority of their time on research; these pathologists would also 

be responsible for classifying pathology material in the repository. 

Aside from the AFIP services discussed above, the BRAC provision 

required that some of AFIP’s other services be retained by DOD and 

relocated into other facilities. For example, the provision requires 

relocating Legal Medicine to the Walter Reed National Military Medical 

Center in Bethesda, Maryland, and the relocation of the Armed Forces 

Medical Examiner, DNA (deoxyribonucleic acid) Registry, and Accident 

Investigation to Dover Air Force Base, Delaware.

As part of its review regarding the disestablishment of AFIP, the BRAC 

Commission found that the medical professional community regarded 

AFIP and its services as integral to the military and civilian medical and 

research community. The commission also found that DOD substantially 

deviated from its selection criteria by failing to sufficiently address several 

AFIP functions. As a result, the commission amended DOD’s initial 

recommendation to add that AFIP capabilities not specified in the final 

recommendation would be absorbed into other DOD, federal, or civilian 

facilities, as necessary. The revised language was approved by the 

President as part of the final BRAC provision. As revised, DOD has the 

flexibility to review AFIP capabilities or services not specifically 

addressed in the BRAC provision to determine which functions to retain. 

As a result of the amendment, the ASD(HA) informed key DOD officials31

in a November 16, 2006, memorandum that he had approved the retention 

of four services—the DOD Veterinary Pathology Residency Program, 

Automated Central Tumor Registry, Center for Clinical Laboratory 

Medicine, and Patient Safety Center. He also informed them that the 

remaining AFIP services would be disestablished unless any of the key 

officials identified the need to retain specific services. Based on responses 

from the key officials, an additional six AFIP services were recommended 

 31These key DOD officials include the Surgeon General of the Army, Surgeon General of the 

Navy, Surgeon General of the Air Force, President of USUHS, and Deputy Director of 

TRICARE Management Activity. 

Page 18 GAO-08-20 Armed Forces Institute of Pathology
for retention. As of September 2007, the ASD(HA) had not made a final 

decision on them. These six services include diagnostic telepathology, two 

biodefense projects, reserve biological select agent inventory, depleted 

uranium (DU) testing, and cystic fibrosis testing. In addition, VA expressed 

an interest in having DOD retain the DU testing capability. Table 4 

summarizes AFIP services that will be relocated or established as 

specified in the BRAC provision, those that were subsequently added by 

the ASD(HA) to be retained, and those that were recommended for 

retention by the DOD officials and are awaiting final decision. (See app. III 

for a description of services currently performed by AFIP that are to be 

retained and relocated, or newly established, or are awaiting final 

decisions.) 

Page 19 GAO-08-20 Armed Forces Institute of Pathology
Table 4: Services Currently Performed by AFIP That Are to Be Retained and Relocated, or Established, or Are Awaiting Final 

Decisions

Service Proposed locationsa

Services required to be retained by the BRAC provision 

Legal Medicine Walter Reed National Military Medical Center, Md. 

National Museum of Health and Medicine Walter Reed National Military Medical Center, Md., managed by 

Uniformed Services University of the Health Sciences (USUHS), Md. 

Repository Forest Glen Annex, Md., managed by Uniformed Services University 

of the Health Sciences (USUHS), Md. 

Armed Forces Medical Examiner, DNA Registry, and 

Accident Investigation 

Dover Air Force Base, Del. 

Enlisted histology technician training Fort Sam Houston, Tex. 

Service to be established as specified by BRAC provision

Program Management Office (PMO) Walter Reed National Military Medical Center, Md. 

Services designated for retention by ASD(HA) 

DOD Veterinary Pathology Residency Program Forest Glen Annex, Md. 

Automated Central Tumor Registry Forest Glen Annex, Md. managed by Uniformed Services of the Health 

Sciences (USUHS), Md. 

Center for Clinical Laboratory Medicine Walter Reed National Military Medical Center, Md. 

Patient Safety Center Walter Reed National Military Medical Center, Md. 

Services being considered for retention by key DOD officials and awaiting a final decision

Diagnostic telepathology Walter Reed National Military Medical Center, Md., or Fort Belvoir, Va.b

Biodefense Project – Joint Biological Agent Identification and 

Diagnostic System 

Fort Detrick, Md. 

Biodefense Project – Critical Reagent Program Aberdeen Proving Ground, Md.b

Reserve Biological Select Agent Inventory Aberdeen Proving Ground, Md.b

Depleted uranium testing Aberdeen Proving Ground, Md.b

Cystic fibrosis testing Outsourced 

Source: GAO analysis of DOD data. 

a

The new locations of Legal Medicine; the Armed Forces Medical Examiner, DNA Registry, and 

Accident Investigation; and enlisted histology technician training were specified in the BRAC 

provision. 

b

As of September 2007, DOD had not finalized decisions regarding the locations of these services. 

Page 20 GAO-08-20 Armed Forces Institute of Pathology
According to DOD’s most recently developed implementation plan,32

execution of the BRAC provision regarding AFIP was scheduled to begin 

in July 2007 and be complete by September 2011. Figure 1 summarizes 

DOD’s plans to terminate AFIP’s three key services by December 2010. It

also illustrates DOD’s timeline that would have relocated other AFIP 

services that were designated to be retained by the BRAC provision. 

Several rounds of staff reductions were anticipated to occur as DOD 

terminated or relocated AFIP services. As figure 1 shows, DOD’s plans left 

a lag time between when AFIP DOD diagnostic consultations ended in 

December 2010 and when the PMO was expected to be operational in 

September 2011. 

Planned Implementation to 

be Completed by 2011 

 32DOD’s most recent BRAC implementation plan pertaining to AFIP was developed in 

February 2007. 

Page 21 GAO-08-20 Armed Forces Institute of Pathology
Figure 1: DOD’s Proposed Timeline for BRAC Implementation Pertaining to AFIP 

Sept.

May

Dec.

Jan.

Aug.

Sept.

Dec.

Sept.

2007 2008 2009 2010 2011

Relocated

Terminated

Source: GAO summary of AFIP data.

Education:

Last CME

course

offered

Education:

Last

Radiologic

Pathologic

Correlation

course

offered

Consultations:

Last civilian 

diagnostic

consultation

Repository

Consultations:

Last military and

other federal

diagnostic

consultation

DOD

Veterinary

Pathology

Residency

Program

Research:

No new

protocols

approved

Legal

Medicine

Program

Management

Office

Armed Forces

Medical

Examiner,

DNA Registry,

Accident

Investigation

Enlisted

histology

technician

training

National

Museum

of Health

and

Medicine

Implementation of these plans were put on hold by the requirements of 

section 3702 of the fiscal year 2007 supplemental appropriations act, 

which suspended all BRAC actions affecting AFIP until after DOD submits 

detailed plans to the House and Senate Appropriations and Armed 

Services Committees, which are due by December 31, 2007. DOD officials 

acknowledge that the timeline as envisioned in their February 2007 

implementation plan can no longer be met and the full amount of onetime 

savings from disestablishment of AFIP will not be realized, although they 

believe that they may still be able to complete all actions required by the 

BRAC provision by 2011. 

While DOD is required to share more information regarding its plans with 

Congress before the end of the year, other developments could impact the

implementation of those plans. Specifically, on May 17, 2007, the House 

Page 22 GAO-08-20 Armed Forces Institute of Pathology
passed H.R. 1585, a bill for the National Defense Authorization Act for 

Fiscal Year 2008, which contains a provision that would require DOD to 

establish a “Joint Pathology Center” at the National Naval Medical Center

in Bethesda. On October 1, 2007, the Senate passed its version of the same 

bill. However, the Senate-passed version contains a provision that would 

authorize, rather than require, DOD to establish a Joint Pathology Center 

at Bethesda, “to the extent consistent with the final recommendations of

the 2005 [BRAC] Commission as approved by the President.” If a new 

Center is established under either provision, it would be required to 

provide diagnostic pathology consultation, pathology education, and 

diagnostic pathology research. In addition, the Senate bill would require 

that the Center, if established, provide maintenance and continued 

modernization of the tissue repository. As of the publication of this report, 

the House and Senate had not reached agreement at conference on any 

provision related to a new Joint Pathology Center. 

Although AFIP is a noted center for pathology expertise, closing AFIP may 

have minimal effect on DOD, VA, and civilian communities because 

pathology services are available to them elsewhere. However, a smooth 

transition depends on DOD’s actions to address key challenges involved in 

developing new approaches to obtaining subspecialty pathology 

consultations and managing the repository to facilitate its use for research. 

DOD and VA officials have begun to identify the challenges, but have not 

decided upon strategies to address them. 

In large part, DOD, VA, and civilian pathologists may be able to obtain 

services elsewhere to replace those currently provided by AFIP. 

Diagnostic consultations: Other medical institutions currently provide 

diagnostic consultations that require subspecialty expertise. For example, 

Massachusetts General Hospital (Boston, Massachusetts) and M. D. 

Anderson Cancer Center (Houston, Texas) each provide about 60,000 or 

more pathology consultations per year. While AFIP has many different 

subspecialty areas, major civilian medical institutions, such as The Johns 

Hopkins Hospital (Baltimore, Maryland) and Memorial Sloan-Kettering 

Cancer Center (New York, New York) have from 10 to 17 different 

Closing AFIP May 

Have Minimal Effect, 

but Management 

Strategy Is Important 

to Address Key 

Challenges 

DOD, VA, and Civilian 

Physicians May Be Able to 

Obtain Key Services from 

Other Institutions 

Page 23 GAO-08-20 Armed Forces Institute of Pathology
subspecialty areas, respectively.

33 Pathologists we interviewed emphasized 

the importance of being able to obtain consultations from expert 

pathologists, wherever they may work. They also stated that pathologists

with particular expertise who move from AFIP to the private sector may 

be able to continue to provide consultations from whichever institutions 

they may join. Most DOD and VA pathologists noted that even though 

MTFs and VA medical centers can readily access AFIP consultations 

without incurring additional fees, they already use subspecialty 

pathologists from civilian medical institutions on occasion for 

consultations due to their needs for particular subspecialty expertise and 

concerns about obtaining a diagnosis in a timely manner. In addition, some 

MTFs have subspecialty pathologists who can provide consultations for 

other military physicians. For example, Brooke Army Medical Center and 

Wilford Hall Medical Center—both located in San Antonio, Texas—each 

have over seven different subspecialty areas. According to pathologists 

from the five MTFs we interviewed, subspecialty pathologists from their 

centers currently provide consultations to other nearby MTFs. 

Pathology education: Other institutions also provide pathology 

education. For example, CAP offers educational courses covering a range 

of topics such as histotechnology and molecular pathology. DOD, VA, and 

civilian pathologists that we interviewed told us that they have fulfilled 

CME requirements through other institutions and could continue to do so. 

Pathologists we interviewed said that DOD and VA pathologists generally 

make independent decisions about which classes to attend and how to 

meet accreditation requirements. Military pathologists we interviewed also

said that due to limited budgets, pathologists generally do not travel to 

AFIP to attend courses because other pathology organizations, such as 

CAP, offer CMEs that are accessible without the need to travel. Most DOD, 

VA, and civilian pathologists we interviewed said that AFIP’s RadiologicPathologic Correlation course is unique and valuable to the radiology 

profession. Some of the pathologists we interviewed said that this is 

because the course utilizes the expertise of physicians who work with 

pathology material from a large volume of difficult-to-diagnose cases, 

 33The American Board of Pathology recognizes 10 different areas of subspecialty pathology

such as cytopathology, dermatopathology, and forensic pathology. Other areas of specialty 

expertise are recognized by military and civilian pathologists from major medical centers 

we interviewed such as genitourinary, gynecology, and breast pathology. Thus, military and 

civilian medical centers determine the number of subspecialties they have in accordance

with the different subspecialties recognized by the American Board of Pathology as well as

those that focus on particular cancers. 

Page 24 GAO-08-20 Armed Forces Institute of Pathology
requires attendees to bring unique specimens for class analysis and 

discussion, and utilizes material from AFIP’s repository, which houses a 

comprehensive collection of specimens. Further, many pathologists and 

representatives from radiology organizations told us that it is the most 

common way radiology residents fulfill a requirement to have specific 

training in pathology. Although the course is recognized as being unique, 

according to guidance set forth by the Accreditation Council for Graduate 

Medical Education, radiologists could fulfill their accreditation 

requirements through avenues other than AFIP. In addition, according to 

DOD officials, it is not DOD’s mission to train civilian radiology residents, 

although we believe that DOD could be in a position to assist outside 

groups if any expressed interest in becoming responsible for maintaining 

the course. 

Research services: The type of research historically conducted by AFIP 

could be conducted at other institutions or by pathologists who remain 

with DOD. USUHS will continue to perform militarily relevant, biomedical 

research, focusing on health promotion and disease prevention, as it gains

responsibility for the repository—AFIP’s primary research tool. 

Additionally, the Office of the Armed Forces Medical Examiner has also 

been responsible for conducting research applicable to military 

operations. Because it is being retained, it could continue to do so. Also, 

AFIP has partnered with other government, academic, and private sector 

institutions to carry out research services. Specifically, AFIP staff have

conducted research affecting general medicine through collaborations 

with external organizations, such as The Johns Hopkins Hospital and the 

Mayo Clinic. These organizations will likely continue to fund medical 

research and could possibly continue to conduct research using pathology 

material from the repository. Although USUHS has not finalized its plans 

regarding the repository, its intent is to make the pathology material 

accessible to others including civilian researchers, to the extent it is 

approved by DOD, practicable, and legally feasible. 

DOD Faces Challenges in 

Ensuring That Military 

Physicians’ Access to 

Subspecialty Consultation 

Services Is Maintained at a 

Reasonable Cost 

Given that AFIP is a central source that provides its customers with 

definitive consults on the most difficult-to-diagnose cases, DOD and VA 

pathologists face challenges in obtaining similar consultative expertise 

once AFIP is disestablished. These challenges include determining how to 

effectively use existing subspecialty pathology resources, obtain outside 

expertise, and ensure coordination and funding of services to encourage 

efficiency while avoiding disincentives to quality care. In addition, DOD 

must decide whether VA could obtain consultation services through the 

PMO and whether VA will be able to provide some subspecialty pathology 

Page 25 GAO-08-20 Armed Forces Institute of Pathology
expertise for DOD. While DOD and VA officials have begun the process to 

identify these challenges, as of mid-August 2007, they had not yet 

developed management strategies to mitigate them. 

Effective utilization of existing resources: While DOD officials told us 

that they might be able to perform some in-house diagnostic consultations 

for MTFs, they have not evaluated their existing medical resources to 

determine the extent to which such consultation services can be 

performed. According to DOD officials, some large MTFs have 

subspecialty expertise and might be able to absorb some of the demand 

for consultations, but DOD has not identified the potential volume and 

type of consultations that these large MTFs could absorb. Further, DOD 

pathologists expressed concerns that MTFs would not be able to absorb 

many additional consultations without increasing the number of 

subspecialty pathologists staffed at MTFs. This could be challenging, they 

said, because it is difficult to retain pathologists within the military. 

Because DOD is retaining some of its pathology capabilities from AFIP 

under the BRAC provision, such as the Armed Forces Medical Examiner, it 

will continue to have expertise available to provide services in the area of

forensic toxicology—DOD’s most frequently used consultation service in 

2006. Further, several DOD officials were concerned that the DOD General 

Counsel’s interpretation of the BRAC provision requiring outsourcing 

through the PMO would preclude DOD from providing second-opinion 

consultations from expertise within its MTFs. In addition, although VA 

may be able to absorb some of its own consultations using its subspecialty

pathologists, including those who are currently assigned to AFIP, VA 

pathologists told us that VA is limited in how many additional 

consultations its current subspecialty pathologists could provide. 

The PMO process: How the PMO functions and obtains diagnostic 

services from medical centers outside DOD and VA has important 

implications, both from a quality of care and a cost standpoint. DOD and 

VA officials we interviewed indicated that DOD faces challenges in 

developing the new PMO that can outsource for quality pathology services; 

such challenges involve issues related to the timeliness of consultations 

and the ability to obtain appropriate expertise at a reasonable cost. As of 

August 2007, DOD has not formulated its management strategies for 

addressing the following issues concerning how the PMO will function. 

• Assisting other federal agencies with obtaining consultations. 

Although DOD has discussed the possibility that the PMO could include 

VA in outsourced diagnostic consultations, no decisions had been made as 

of mid-August 2007. Since VA has received over a quarter of AFIP’s total 

Page 26 GAO-08-20 Armed Forces Institute of Pathology
consultations, VA officials have expressed an interest in continuing to 

receive consultations through the PMO once DOD discontinues offering 

AFIP consultations. VA officials also expressed concerns about the cost of

obtaining consultations outside of AFIP, which they estimated to be much 

greater than the financial support it currently provides to AFIP for its 

services. In addition, the officials stated that AFIP has been responsible 

for VA’s DU program,34 and as of June 2007, VA officials were uncertain 

about the extent to which staff and equipment providing these services 

would be sufficient to meet the future needs. VA officials stated that their

agency did not have the equipment or expertise to conduct the analyses 

needed for this program, and for testing of other types of embedded 

fragments, such as cobalt, nickel, and tungsten. VA officials indicated that

testing for DU and other potentially harmful embedded fragments plays an 

important role in providing high quality health care to recently injured 

combat veterans. As we previously discussed in this report, DOD officials 

are considering the possibility of retaining DU testing. 

• Obtaining consultation services. Several military pathologists 

expressed concerns about the challenges DOD and VA would face in

identifying and obtaining needed subspecialty expertise from pathologists. 

These concerns stem, in part, from their understanding of AFIP’s 

capabilities to provide consultations for difficult-to-diagnose cases by 

involving different types of subspecialty pathologists as needed. Within 

AFIP, cross-consultation among experts is available under one roof. As 

DOD will have to determine a new method for obtaining consultations 

using the PMO, military pathologists expressed concerns that it might be 

more difficult to access expertise dispersed among different institutions to 

obtain accurate diagnostic information. DOD and VA pathologists also 

expressed concerns regarding whether continuity of patient care would be 

maintained for retired military personnel if pathology specimens from 

active duty personnel and veterans are no longer sent to one central 

laboratory, such as AFIP. At present, if a patient has had a previous 

consultation, the material is available from the repository for comparison 

if AFIP is requested to conduct another consultation at a later date for the 

same patient. This can be important for the patient’s care—for example, in 

 34The VA DU program is responsible for providing clinical surveillance to veterans and 

active duty personnel who have the highest risk of DU exposure (primarily those with 

retained DU fragments). Currently, the DU program relies on AFIP to perform analyses of 

specimens from veterans and active duty personnel potentially exposed to DU. The AFIP 

laboratory is one of the few facilities nationwide that are able to measure very low 

concentrations of uranium in urine, blood, and semen specimens with a high degree of 

accuracy and to discriminate between natural uranium and depleted uranium based on 

isotopic analysis. 

Page 27 GAO-08-20 Armed Forces Institute of Pathology
determining if a patient’s cancer is metastasizing or if a precancerous 

condition is worsening. AFIP pathologists expressed concern that patient 

care could be compromised if the pathologists providing consultations 

could no longer obtain their patients’ previous specimens, slides, or case 

notes from the repository. In addition, according to an AFIP pathologist, 

the repository is particularly valuable for AFIP’s consultation services 

because it can serve as a reference tool to compare pathology material 

from one patient to that of many others to confirm a diagnosis. VA and 

AFIP pathologists have raised concerns about whether alternate sources 

of consultation services obtained through the PMO will be able to provide 

the same continuity or quality of service unless pathologists from these 

alternate sources can use the repository as a reference. Further, DOD 

pathologists expressed concern about whether private sector institutions 

with the best subspecialty pathology expertise can absorb the 40,000 

consultations that have been conducted by AFIP annually. DOD 

pathologists also indicated that as of August 2007, DOD had not yet 

developed a management strategy to address this challenge. 

• Timeliness of consultation services. DOD pathologists we interviewed 

are also concerned that obtaining consultations may take longer than it 

does under AFIP because it is unclear how DOD will identify and obtain 

needed pathology expertise. Timeliness of consultation services is 

important. For example, understanding the aggressiveness and particular 

stage of a cancer in a given point in time can influence patient treatments 

and outcomes. Some pathologists also anticipate that turnaround time for 

DOD’s consultations may increase due to difficulty coordinating among 

pathologists with varied subspecialty expertise that are dispersed among 

different institutions and that this could impair the quality of services that 

DOD obtains. As of August 2007, DOD had not outlined the management 

strategy that it will pursue to ensure timely access to consultative services. 

• Funding mechanisms. DOD pathologists’ access to subspecialty 

pathology expertise can also be impacted depending on how DOD plans to 

mitigate funding incentives related to centralization or decentralization of 

the budget. According to DOD officials, as of July 2007, DOD had not made 

decisions regarding whether the budget for consultations would be 

maintained centrally at the PMO or if each MTF would receive a separate

budget for outsourced consultations. Because DOD pathologists did not 

have to pay for AFIP’s consultation services, there was no financial 

disincentive to use them. Several pathologists we interviewed expressed 

concern that decentralized funding for consultation services would create 

disincentives to obtaining consultations and could ultimately affect the 

quality of the medical care the military would receive for such services. 

More specifically, these officials asserted that a decentralized funding 

Page 28 GAO-08-20 Armed Forces Institute of Pathology
system would require a Department of Pathology Chair within an MTF to 

scrutinize the department’s competing demands for resources and make 

decisions about whether to obtain outside pathology expertise or spend 

financial resources on other patient care needs. VA pathologists also 

expressed concern that funding issues could contribute to increasing the 

difficulty of obtaining subspecialty consultations. If pathologists cannot 

obtain subspecialty consultations when they are unsure of their diagnosis, 

patients might be misdiagnosed. This is particularly relevant since, as we 

discussed earlier in this report, AFIP has changed requesting physicians’ 

initial diagnoses for about 43 percent of the cases it reviews. 

• Minimizing costs of services through volume discounts. By working 

with VA, DOD could further increase its economies of scale by purchasing 

a higher volume of consultation services. However, several DOD and VA 

pathologists expressed concerns that if DOD chooses to obtain services 

from the lowest bidder, the quality of consultations could be 

compromised. They informed us that large national laboratories would 

likely be the lowest bidders, but these institutions might lack the 

subspecialty expertise to provide the best services. In fact, such large 

national laboratories currently use AFIP consultation services. Further, 

DOD pathologists we interviewed expressed concern for their patients’ 

care with respect to whether DOD would obtain the best subspecialty 

consultations possible. 

DOD has formed a working group, which met for the first time in August 

2007, to address issues pertaining to obtaining consultations. This group 

includes representatives from the Offices of the Surgeons General of the 

Army, Navy, and Air Force, as well as other DOD and VA officials. 

According to DOD officials, the workgroup spent its first meeting 

identifying the challenges faced by DOD in obtaining needed expertise but 

had not yet developed specific options to address the challenges. 

Page 29 GAO-08-20 Armed Forces Institute of Pathology
Because DOD has not developed its strategy regarding how it will 

populate, maintain, and use the repository, some pathologists we 

interviewed were concerned about the future of the repository and 

whether it would continue to be a viable research tool. Recently, USUHS 

awarded a contract to study the usefulness of the pathology material in the 

repository.35 According to DOD, once that study is completed in October

2008, USUHS plans to convene a panel of experts to develop a blueprint on

how to use the repository for research, and then will likely contract for 

development of a detailed plan on how to best populate, manage, and use 

the repository. USUHS does not intend to finalize key decisions until that 

process is complete. 

USUHS officials told us that one of the challenges they face in the future is 

how they will populate pathology material in the repository in order to 

maintain its viability as a research tool. They explained that AFIP generally

populates its repository through pathology material obtained from its 

consultation services. As a result, the repository includes material from 

the DOD, VA, and civilian populations. Additionally, AFIP’s RadiologicPathologic Correlation course has historically contributed to the growth of 

pathology material in the repository because students, who are primarily 

civilians, are required to submit samples to AFIP that have pathologic 

significance. We estimate that the repository gains approximately 1,200 to

2,400 samples per year from students attending this course. Pathologists 

we interviewed explained that the value of the material in the repository is 

related to the number of cases it accumulates for a particular disease. That

is, in order for a researcher to be able to identify the characteristic 

patterns of a disease allowing for its diagnosis and treatment, there must 

first be a sufficient number of cases of the particular disease. USUHS 

officials told us that due to the large volume of cases that AFIP 

accumulated in the repository, including complex cases, researchers can 

currently conduct studies of considerable sample size. Thus, the manner in

which USUHS plans to continue to accumulate material in the repository 

can influence the pace of research. 

Because USUHS does not provide pathology consultations, in the absence 

of civilian consultations it will need to develop other strategies to populate 

the repository. The strategy that USUHS officials discussed with us was to 

Research Could Be 

Affected Depending on 

How DOD Plans to 

Populate, Maintain, and 

Use the Repository in the 

Future 

 35The study of the material in the repository would include a review of the physical tissue 

samples (i.e., clinical records, blocks of tissue embedded in paraffin, slides, and gross 

samples of tissue) and the quality of the linkage between the medical record and tissue 

samples.

Page 30 GAO-08-20 Armed Forces Institute of Pathology
populate the repository with specimens from military hospitals. Populating 

the repository in this manner, however, could skew the repository since 

military hospitals generally draw patients that are largely young, male, and 

active. This could decrease the usefulness of the repository, ultimately 

affecting the breadth of research. As a result, it is important that USUHS 

develop a strategy to determine how it will populate the repository, 

considering both the quantity of pathology material for each disease as 

well as the quality and type of material from which it draws. 

DOD, VA, and civilian pathologists we interviewed also recognize that 

proper maintenance of pathology material is necessary for retaining the

repository’s optimal usefulness. Specifically, as medical knowledge of 

tumors and other conditions evolves, material requires reclassification by 

pathologists with subspecialty expertise in order to be useful. As such, 

repositories can become useless without continuous update and 

evaluation. Officials from academic centers that we spoke with said that 

the failure to preserve, maintain, and update the repository would be a 

tremendous loss to pathology, and general medicine overall. USUHS 

officials said that having staff pathologists with subspecialty expertise 

responsible for properly classifying pathology material is important to the 

repository’s viability. USUHS discussed with us that it may employ about 

10 to 12 pathologists with subspecialty expertise who would be 

responsible for reclassifying material in the repository as needed. 

USUHS officials expressed a desire to expand the use of the repository to 

others outside of DOD—such as pharmaceutical companies and 

cooperative ventures with other academic institutions—so that the 

repository’s role in general medical research could continue and benefit 

the general population. However, USUHS officials said that they first need 

to determine policy, financial, and legal ramifications, such as patient 

privacy issues, before they make any decisions regarding research access 

to the repository assets. USUHS officials also told us that the pathologists 

they hire would have access to pathology material in the repository and 

would also be responsible for conducting militarily relevant research. 

AFIP is a noted institution that has provided pathology expertise in a 

range of subspecialty areas, and its customers value the services that it 

provides. Congress has mandated that DOD provide a detailed plan on 

disestablishing AFIP by December 2007, which gives DOD an opportunity 

to address potential challenges involved with closing the facility. DOD 

awarded a contract to study the usefulness of the material in the 

repository, which it anticipates to be completed by the end of 2008. DOD 

Conclusions 

Page 31 GAO-08-20 Armed Forces Institute of Pathology
anticipates using the study, a subsequent panel of experts, and a possible 

second contract to develop a detailed implementation plan to help make 

decisions on how the repository will be managed. As part of its planning 

process, it is critical for DOD’s plan to go beyond the steps to terminate, 

relocate, or outsource AFIP’s services and include implementation 

strategies that detail how it will organize consultation services and manage 

the repository in the future. DOD has not yet developed these strategies—

strategies that could help mitigate potential negative impacts of 

disestablishing AFIP and facilitate a smooth transition as DOD looks to 

other sources for obtaining high-quality pathology services. 

As part of DOD’s initiative to develop a plan for disestablishing AFIP, we 

are making three recommendations to the Secretary of Defense that could 

help mitigate potential negative impacts of disestablishing AFIP. 

Recommendations for 

Executive Action 

• We recommend that the Secretary of Defense include in the December 

2007 plan to Congress implementation strategies for how DOD will use 

existing in-house pathology expertise available within MTFs, identify and 

obtain needed consultation services from subspecialty pathologists with 

appropriate expertise through the PMO in a timely manner, and solidify 

the source and organization of funds to be used for outsourced 

consultation services. 

• Within 6 months of completion of DOD’s study regarding the usefulness of 

the pathology material in the repository that is to be finished in October 

2008, the Secretary should require USUHS to provide Congress with 

information on the status of the repository’s assets and their potential for

research use.

• Prior to USUHS assuming responsibility for the repository, the Secretary 

should provide a report to Congress on its implementation strategies for 

how it will populate, manage, and use the repository in the future. The 

implementation strategies should include information on how USUHS 

intends to use pathology expertise to manage the material, obtain 

pathology material from a wide variety of individuals, maximize 

availability of the repository for research through cooperative ventures 

with other academic institutions, and assist interested groups—if any—in 

supporting the continuation of educational services, such as the 

Radiologic-Pathologic Correlation course. 

Page 32 GAO-08-20 Armed Forces Institute of Pathology
DOD and VA provided written comments on a draft of this report, included 

in appendix IV and appendix V. In commenting on a draft of this report, 

DOD concurred with the report’s findings and conclusions and fully 

concurred with our recommendation for DOD to include its 

implementation strategies for organizing future pathology consultation 

services in its December 2007 plan to the Congress. However, DOD 

partially concurred with the recommendation to report to the Congress 

within 6 months of completing its study on the viability of the repository. 

Specifically, DOD indicated that USUHS would not be in a position to 

report its strategies on managing the repository until further work was 

completed. As a result, we modified our recommendation to limit the 

reporting requirement to information on the viability of material in the 

repository and its usefulness for research. We also added another 

recommendation that DOD should report to Congress at a later date on 

USUHS’s planned strategies for managing the repository. In its written 

comments, VA agreed that the draft report was factually accurate, but 

indicated that it did not fully capture the essential nature of AFIP’s 

services to VA and DOD or fully address the impact of its closing. We 

believe that we provided a balanced assessment of AFIP’s services and the 

impact of its closing. 

In its comments, DOD agreed with the description of the challenges it 

faces in developing new approaches to obtaining pathology expertise 

through the PMO and managing the repository to ensure that it remains a 

rich resource for civilian and military research. DOD emphasized that it 

was in the process of developing alternative strategies that would be 

coordinated internally and with VA to ensure that the strategies would 

meet DOD’s needs, assist the VA, and be in accordance with BRAC 

recommendations. DOD concurred with our recommendation that the 

Secretary of Defense should include in the December 2007 plan to 

Congress implementation strategies for how DOD will use existing inhouse pathology expertise available within MTFs, identify and obtain 

needed consultations from subspecialty pathologists with appropriate 

expertise through the PMO in a timely manner, and solidify the source and 

organization of funds to be used for outsourced consultation services. In 

addition, DOD agreed that the Secretary of Defense should submit a plan 

to Congress within 6 months of completion of the repository evaluation 

contract to provide information on the status of pathology material in it 

and its research potential. However, DOD indicated that the results of the 

evaluation contract will likely result in another contract to help develop a 

detailed strategy on how USUHS will populate, manage, and use the 

repository. Therefore, DOD will not be able to report on how USUHS will

populate, manage, and use the repository within 6 months of completion 

Agency Comments 

and Our Evaluation 

Page 33 GAO-08-20 Armed Forces Institute of Pathology
of the repository evaluation contract and did not concur with that portion 

of the draft recommendation. Given this, we modified our 

recommendations in this report to reflect the steps DOD anticipates 

taking. Specifically, we separated the recommendations to address 

reporting on the viability of the repository material and the strategies for 

its maintenance and use.

In commenting on a draft of this report, VA indicated that the report was 

factually accurate, but did not sufficiently describe the potential impact 

associated with closing AFIP. VA focused on five concerns—DU testing, 

stagnation of the repository, difficulties in replacing AFIP’s consultation 

services and obtaining them through the PMO, potential impact on patient

care, and the potential costs to replace existing services. 

• VA commented that AFIP’s testing of DU and other types of potentially 

harmful embedded fragments was essential to providing quality health 

care to recently injured veterans. VA indicated that our report did not 

sufficiently emphasize the importance of these AFIP services. While the 

report clearly states that DOD is considering retaining DU testing, we 

added additional text in this report to highlight VA’s concerns, including 

those about testing other types of potentially harmful embedded 

fragments. 

• VA also indicated that the repository contained a large archive of veterans’ 

pathology specimens that would be invaluable for future clinical and

research endeavors and expressed concern that DOD will allow the 

repository to stagnate upon closure of AFIP. Our report acknowledges the 

importance of the repository to veterans’ care. This is why we discussed 

the challenges of maintaining a viable repository in the report and made a

specific recommendation that DOD provide information on future plans 

for it. 

• Regarding consultation services, VA expressed concerns that other 

institutions may not have the capacity to absorb AFIP’s workload; some 

types of services might not be available; and obtaining services through 

the PMO may adversely affect timeliness and make it more complex and 

inefficient for local facilities to obtain pathology services. In our report, 

we discussed such concerns and stated that DOD faces challenges in 

obtaining expertise similar to what AFIP offered. As a result, we 

recommended that DOD report to the Congress on how it would address 

these challenges and obtain pathology services in the future. 

Page 34 GAO-08-20 Armed Forces Institute of Pathology
• VA stated that the report did not fully discuss the impact of closing AFIP 

on patient care—especially the significance of changing diagnoses and of

providing timely services. We disagree. The draft report clearly states that

changing a diagnosis can lead to different treatment and, ultimately, a 

different outcome for the patient. The report also states that timeliness is 

important because it can affect patient treatment and outcomes. VA 

appears to assume that DOD will not be able to obtain timely and quality 

consultative services through the PMO. In the report, we stated that 

obtaining quality consultation services in a timely manner through the 

PMO is one of the challenges that DOD would have to address. Until DOD 

develops its strategies, we would not have a basis to determine whether it 

would be likely to meet this challenge. 

• VA commented on the potential high cost in procuring alternative sources 

for AFIP’s services. We did not conduct an overall assessment of whether 

it would cost DOD more to obtain consultations from other sources than it 

would to maintain AFIP. DOD considered costs when developing its 

recommendation to the BRAC commission to outsource consultations. 

However, as we have reported previously, implementing other BRAC 

recommendations has led to lower cost savings than DOD had estimated.36

Regarding the costs for VA, we state in our report that earlier studies had 

found that the costs of the services that AFIP provided to VA exceeded the 

value of the paid positions VA provided in exchange. AFIP officials 

indicated that this continued to be true in fiscal year 2007. As a result, 

depending on how and where VA obtains consultation services, its costs 

could increase. 

As agreed with your offices, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days from 

this date. At that time, we will send copies of this report to the Secretary 

of Defense, the Secretary of VA, appropriate congressional committees, 

and other interested parties. We will also make copies available to others

upon request. In addition, the report will be available at no charge on 

GAO’s Web site at http://www.gao.gov. If you or your staff have any 

questions about this report please contact me at (202) 512-7114 or 

williamsonr@gao.gov. Contact points for our Offices of Congressional 

 36GAO, Military Base Realignments and Closures: Observations Related to the 2005 

Round, GAO-07-1203R (Washington, D.C.: Sept. 6, 2007). 

Page 35 GAO-08-20 Armed Forces Institute of Pathology
Relations and Public Affairs may be found on the last page of this report. 

GAO staff who made major contributions to this report are listed in 

appendix VI.

Randall B. Williamson 

Director, Health Care 

Page 36 GAO-08-20 Armed Forces Institute of Pathology
Appendix I: Scope and Methodology 

Page 37 GAO-08-20 Armed Forces Institute of Pathology

Appendix I: Scope and Methodology 

To describe key services that the Armed Forces Institute of Pathology 

(AFIP) provides to the Department of Defense (DOD), the Department of 

Veterans Affairs (VA), and civilian communities, we reviewed recent 

reports describing AFIP’s services and business practices, including a 

previous GAO report1

 and an Army Audit Agency report on AFIP’s 

business plan2

 and a BearingPoint report on AFIP’s capabilities,3 and other 

relevant reports, including some from VA. We also interviewed officials 

from AFIP, DOD, VA, the American Registry of Pathology (ARP), 

pathology associations such as the College of American Pathologists 

(CAP), the American Society for Investigative Pathology, and the 

Association of Pathology Chairs, as well as radiology associations, such as

the American College of Radiology and the Canadian Radiology 

Association, to collect information on AFIP’s core services. Additionally, 

we obtained data from AFIP on the services it provides. To assess the 

reliability of these data, we interviewed knowledgeable agency officials 

and reviewed related documentation. We determined that the data were 

sufficiently reliable for the purposes of this report. 

To describe DOD’s plans to terminate, relocate, or outsource services 

currently provided by AFIP, as required by the Base Realignment and 

Closure (BRAC) provision, we interviewed officials from DOD’s Offices of 

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

Assistant Secretary of Defense for Health Affairs; the Office of the General 

Counsel; the TRICARE Management Activity; the Office of the Deputy 

Under Secretary of Defense (Installations and Environment); AFIP; and 

the Uniformed Services University of the Health Sciences (USUHS). We 

also interviewed pathologists from military treatment facilities (MTF) and 

VA medical centers. In addition, we reviewed the BRAC business plan for 

the Walter Reed Army Medical Center and related assumptions and 

analysis that led to the BRAC decisions. 

 1

GAO, Armed Forces Institute of Pathology: Business Plan’s Implementation Is Unlikely

to Achieve Expected Financial Benefits and Could Reduce Civilian Role, GAO-05-615 

(Washington, D.C.: June 30, 2005). 

2

U.S. Army Audit Agency, Armed Forces Institute of Pathology, Audit Report: A-2006-0170-

FFH (Alexandria: August 2006). 

3

BearingPoint, Review of Armed Forces Institute of Pathology Capabilities Recommended 

for Disestablishment by the Defense Base Closure and Realignment Commission 2005, 

May 2006. 
Appendix I: Scope and Methodology 

To assess the potential impacts of disestablishing AFIP on the military and 

civilian communities, we interviewed pathologists from AFIP, ARP, five 

MTFs and five VA medical centers, as well as civilian pathologists from 

four major medical centers. We interviewed representatives from 

pathology and radiology associations, including ARP, CAP, the American 

Society for Investigative Pathology, the Association of Pathology Chairs, 

the American College of Radiology, and the Canadian Association of 

Radiologists, to obtain their views regarding the potential impact of 

discontinuing AFIP’s core services. In addition, we reviewed data from 

various reports and other documents to assess the potential impact of 

discontinuing the three key services as AFIP currently provides. We 

performed our work from March 2007 through November 2007 in 

accordance with generally accepted government auditing standards. 

Page 38 GAO-08-20 Armed Forces Institute of Pathology
Appendix II: M

Institute 

C

aps of the Armed Forces 

of Pathology’s (AFIP) 2006 

onsultations 

Page 39 GAO-08-20 Armed Forces Institute of Pathology

Appendix II: Maps of the Armed Forces 

Institute of Pathology’s (AFIP) 2006 

Consultations 

In 2006, AFIP provided almost half of its consultations for DOD, with the 

rest predominantly for VA and civilian physicians. (See fig. 2 for the 2006 

distribution of AFIP’s DOD consultations, fig. 3 for its VA consultations, 

and fig. 4 for its civilian consultations.) 

Figure 2: AFIP’s DOD Consultations for 2006 

Low: 1-299 

Medium: 300-599

High: 600+

Sources: GAO summary of AFIP data; Copyright © Corel Corp. All rights reserved; MapArt (map).

Pa.

12

Ore.

2

Nev.

284

Idaho

27

Mont.

4

Wyo.

6

Utah

66

Ariz.

238 N.M.

28

Colo.

659

N.D.

16

S.D.

18

Neb.

212

Tex.

1,519

Kan.

141

Okla.

231

Minn.

3

Iowa

1

Mo.

180

Ark.

52

La. 

150

Ill.

270

Miss.

243

Ind.

2

Ky.

690

Tenn.

2

Ala.

88

Fla.

820

Ga.

1,220

S.C.

291

N.C.

1,371

Va.

1,476

Ohio

467

N.H. 0

Mass. 6

R.I. 0 Mich.

1

Calif.

1,974

Wash.

671

Wis.

13

N.Y.

1,614

Maine

10

Vt.

0

W.Va

0

Alaska

487

Hawaii

1,030

Guam

5

Conn. 69

N.J. 48

Del. 82

Md. 1,492

D.C. 988

P.R.

0

V.I.

0
Appendix II: Maps of the Armed Forces 

Institute of Pathology’s (AFIP) 2006 

Consultations 

Figure 3: AFIP’s VA Consultations for 2006 

Low: 1-299 

Medium: 300-599

High: 600+

Sources: GAO summary of AFIP data; Copyright © Corel Corp. All rights reserved; MapArt (map).

Pa.

616

Ore.

55

Nev.

109

Idaho

62

Mont.

135

Wyo.

39

Utah

80

Ariz.

390 N.M.

63

Colo.

151

N.D.

161

S.D.

95

Neb.

102

Tex.

341

Kan.

130

Okla.

183

Minn.

143

Iowa

72

Mo.

329

Ark.

535

La. 

100

Ill.

1,154

Miss.

225

Ind.

48

Ky.

809

Tenn.

205

Ala.

102

Fla.

1,109

Ga.

376

S.C.

396

N.C.

769

Va.

331

Ohio

731

N.H. 40

Mass. 97

R.I. 38 Mich.

189

Calif.

801

Wash.

59

Wis.

68

N.Y.

831

Maine

133

Vt.

10

W.Va

647.

Alaska

0

Hawaii

0

Guam

0

Conn. 28

N.J. 151

Del. 181

Md. 417

D.C. 138

P.R.

62

V.I.

0

Page 40 GAO-08-20 Armed Forces Institute of Pathology
Appendix II: Maps of the Armed Forces 

Institute of Pathology’s (AFIP) 2006 

Consultations 

Figure 4: AFIP’s Civilian Consultations for 2006 

Low: 1-299 

Medium: 300-599

High: 600+

Sources: GAO summary of AFIP data; Copyright © Corel Corp. All rights reserved; MapArt (map).

Pa.

923

Ore.

24

Nev.

143

Idaho

6

Mont.

29

Wyo.

26

Utah

14

Ariz.

187 N.M.

17

Colo.

23

N.D.

8

S.D.

3

Neb.

18

Tex.

182

Kan.

70

Okla.

37

Minn.

29

Iowa

11

Mo.

147

Ark.

28

La. 

66

Ill.

375

Miss.

98

Ind.

32

Ky.

96

Tenn.

54

Ala.

33

Fla.

1,053

Ga.

152

S.C.

96

N.C.

386

Va.

866

Ohio

389

N.H. 15

Mass. 103

R.I. 32 Mich.

126

Calif.

453

Wash.

44

Wis.

29

N.Y.

802

Maine

75

Vt.

7

W.Va

158.

Alaska

9

Hawaii

148

Guam

42

Conn. 150

N.J. 641

Del. 118

Md. 1,057

D.C. 361

P.R.

104

V.I.

50

Page 41 GAO-08-20 Armed Forces Institute of Pathology
Appendix III: Description of Services 

Performed by the Armed Forces Institute of 

Pathology (AFIP) 

Page 42 GAO-08-20 Armed Forces Institute of Pathology 

Appendix III: Description of Services 

Performed by the Armed Forces Institute of 

Pathology (AFIP) 

Legal Medicine: Legal Medicine provides consultation, education, and 

research on medical legal, quality assurance, and risk management issues 

to the Department of Defense (DOD); manages a registry of closed DOD 

medical malpractice cases; manages the DOD Centralized Credentials 

Quality Assurance System; assists the Uniformed Services University of 

the Health Sciences (USUHS) with the masters degree program in 

Forensic Sciences; awards continuing medical education (CME) credits in 

medical legal, quality assurance, and risk management to nurses and 

physicians; and publishes the journals Legal Medicine and Nursing Risk 

Management. 

National Museum of Health and Medicine: The National Museum of 

Health and Medicine was established during the Civil War as the Army 

Medical Museum. The Museum promotes the understanding of medicine 

from past, present, and future, with a special emphasis on American 

military medicine. It has five major collections: Anatomical, Historical, 

Otis Historical Archives, Human Developmental Anatomy Center, and 

Neuroanatomical, which are estimated to contain more than 24 million 

objects. 

Repository: The National Pathology Repository contains approximately 

3 million case files and associated paraffin blocks, microscopic glass 

slides, and formalin-fixed tissue specimens. Tens of thousands of cases are 

added to the repository each year. Staff code all material for future 

research use.

The Office of the Armed Forces Medical Examiner, DNA 

(deoxyribonucleic acid) Registry, and Accident Investigation: The 

Office of the Armed Forces Medical Examiner conducts scientific forensic 

investigations for determining the cause and manner of death of members 

of the Armed Forces and of civilians whose deaths come under exclusive 

federal jurisdiction. The office provides consultative services in forensic 

pathology, forensic toxicology, forensic anthropology, and DNA 

technology, as well as on-site medical legal investigations of military 

accidents. It is the only federal resource of its kind, so other federal 

agencies frequently use its services. The DOD DNA Registry is at the 

forefront of nuclear and mitochondrial DNA technology, supports the 

Office of the Armed Forces Medical Examiner in identification, and serves 

as the repository for specimens obtained from military personnel to be 

used for identification. 
Appendix III: Description of Services 

Performed by the Armed Forces Institute of 

Pathology (AFIP) 

Enlisted histology technician training: The Tri-Service School of 

Histotechnology is the only military histopathology training program, 

according to a DOD official. It consists of 180 training days in the technical 

operations of anatomic pathology. Training includes instruction in the 

theory and application of histotechnology and practical training in the 

fixation, processing, embedding, microtomy, and staining of tissue 

specimens prior to examination by a pathologist. The curriculum also 

includes instruction and practical experience as a postmortem 

examination (autopsy) assistant. 

Program Management Office (PMO): The PMO will be newly 

established to coordinate pathology results, contract administration, and 

quality assurance and control of DOD second-opinion consults worldwide. 

DOD Veterinary Pathology Residency Program: The DOD Veterinary 

Pathology Residency Program is a 3-year postdoctoral training program. 

Residents are involved in consultation, education, and research during the 

program. The residency culminates in a 2-day examination given by the 

American College of Veterinary Pathologists, and successful completion of 

this examination results in board certification in veterinary anatomic 

pathology. 

Automated Central Tumor Registry: The Automated Central Tumor 

Registry provides the uniformed services MTFs with the capability to 

compile, track, and report cancer data on DOD beneficiaries. The 

objective of the registry is to maintain a research quality database for 

cancer reporting that supports outcome analysis, referral patterns, trend 

analysis, statistical reporting, health care analysis, epidemiology, and 

uniform data collection and tracking. 

Center for Clinical Laboratory Medicine: The Center for Clinical 

Laboratory Medicine directs the operation of the DOD Clinical Laboratory 

Improvement Program, as defined by DOD Instruction 6440.2 and Public 

Law No. 100-578; administers law and federal policy for military medical 

laboratory operations in peace, contingency, and wartime, ensuring that 

no restrictions or cessation of laboratory services impedes DOD mission 

requirements; and acts as gatekeeper for DOD and Centers for Disease 

Control and Prevention (CDC) initiatives to develop a biological warfare 

detection and response system, that is, National Laboratory Response 

Network. 

Page 43 GAO-08-20 Armed Forces Institute of Pathology 
Appendix III: Description of Services 

Performed by the Armed Forces Institute of 

Pathology (AFIP) 

Patient Safety Center: The Patient Safety Center manages a 

comprehensive patient safety data registry for DOD. The DOD Patient 

Safety Registry is a database that gathers standardized clinically relevant 

information about all instances and categories of actual events and close 

calls. This registry is used to identify and provide feedback on systemic 

patterns and practices that place DOD patients at risk, and thereby it 

stimulates, initiates, and supports local interventions designed to reduce 

risk of errors and to protect patients from inadvertent harm. The Patient 

Safety Center publishes DOD Patient Safety Alerts, and it produced the 

first Patient Safety Toolkit targeting patient fall reduction. 

Diagnostic telepathology: The practice of pathology involves using 

telecommunications to transmit data and images between two or more 

sites remotely located from each other, according to a DOD official. The 

data include clinical information about the patient, such as signs, 

symptoms, treatment, and response; gross description of the surgical 

specimen(s); and digital images of the processed specimen. These data are 

transmitted electronically, allowing a pathologist practicing in a 

geographically distant site to consult another pathologist for a second 

opinion, or to consult other pathologists who are experts on particular 

disease processes. 

Biodefense Project – The Joint Biological Agent Identification and 

Diagnostic System: The Joint Biological Agent Identification and 

Diagnostic System pertains to a rapid identification and diagnostic 

confirmation of biological agent exposure or infection, according to a 

DOD official. The standalone system consists of a portable unit to perform 

sample analysis, a laptop computer for readout display and assay reagent

test kits to identify multiple biological warfare agents, infectious disease 

agents, and biological toxins. 

Biodefense Project – The Critical Reagent Program: The Critical 

Reagent Program provides bulk quantities of DNA extracted from selected 

biological threat agents, according to a DOD official. These are then used 

to develop validated, high-quality immunological and DNA-based 

biodetection reagents to support different biological warfare agent 

detector platforms. 

Reserve Biological Select Agent Inventory: The Reserve Biological 

Select Agent Inventory is registered with CDC and with the Army Medical 

Command, and includes over 1,500 strains of controlled biological select 

agents and toxins, according to a DOD official. These are stored in freezers 

in secure Biosafety Laboratory level 3 areas of AFIP. Storage, use, and 

Page 44 GAO-08-20 Armed Forces Institute of Pathology 
Appendix III: Description of Services 

Performed by the Armed Forces Institute of 

Pathology (AFIP) 

transfer of any agents or toxins is strictly controlled and regulated by CDC 

and Army regulations. 

Depleted uranium (DU) testing: DU Urine Testing supports medical 

surveillance programs by measuring the levels of uranium in patients’ 

urine and identifies the specific source of exposure by accurately 

measuring uranium isotopic ratios, according to a DOD official. DU 

Testing in Body Fluids and Tissue provides chemical analysis of embedded 

DU fragments in tissues removed from shrapnel wounds. 

Cystic fibrosis testing: A test for cystic fibrosis is one of several tests for 

genetically inherited diseases that are recommended by the Department of 

Health and Human Services’ Health Resources and Services 

Administration and the American College of Medical Genetics. AFIP 

ceased cystic fibrosis testing on June 1, 2007. All DOD cystic fibrosis tests 

are currently being performed by commercial labs or other DOD labs. 

Page 45 GAO-08-20 Armed Forces Institute of Pathology 
Appendix IV: Comments from the Department 

of Defense 

Page 46 GAO-08-20 Armed Forces Institute of Pathology

Appendix IV: Comments from the 

Department of Defense 
Appendix IV: Comments from the Department 

of Defense 

Page 47 GAO-08-20 Armed Forces Institute of Pathology
Appendix V: Comments from the Department 

of Veterans Affairs 

Page 48 GAO-08-20 Armed Forces Institute of Pathology

Appendix V: Comments from the Department 

of Veterans Affairs 
Appendix V: Comments from the Department 

of Veterans Affairs 

Page 49 GAO-08-20 Armed Forces Institute of Pathology
Appendix V: Comments from the Department 

of Veterans Affairs 

Page 50 GAO-08-20 Armed Forces Institute of Pathology
Appendix VI: 

A

GAO Contact and Staff 

cknowledgments 

Page 51 GAO-08-20 Armed Forces Institute of Pathology

Appendix VI: GAO Contact and Staff 

Acknowledgments 

GAO Contact Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov

In addition to the contact named above, Sheila Avruch, Assistant Director; 

Adrienne Griffin; Cathy Hamann; Nora Hoban; Jasleen Modi; 

Carolina Morgan; and Andrea Wysocki made key contributions to this 

report. 

Acknowledgments 
Related GAO Products 

Page 52 GAO-08-20 Armed Forces Institute of Pathology

Related GAO Products 

Military Base Realignments and Closures: Transfer of Supply, Storage, 

and Distribution Functions from Military Services to Defense Logistics 

Agency. GAO-08-121R. Washington, D.C.: October 26, 2007. 

Defense Infrastructure: Challenges Increase Risks for Providing Timely 

Infrastructure Support for Army Installations Expecting Substantial 

Personnel Growth. GAO-07-1007. Washington, D.C.: September 13, 2007. 

Military Base Realignments and Closures: Plan Needed to Monitor 

Challenges for Completing More Than 100 Armed Forces Reserve 

Centers. GAO-07-1040. Washington, D.C.: September 13, 2007. 

Military Base Realignments and Closures: Observations Related to the 

2005 Round. GAO-07-1203R. Washington D.C.: September 6, 2007. 

Military Base Closures: Projected Savings from Fleet Readiness Centers

Likely Overstated and Actions Needed to Track Actual Savings and 

Overcome Certain Challenges. GAO-07-304. Washington, D.C.: June 29, 

2007. 

Military Base Closures: Management Strategy Needed to Mitigate 

Challenges and Improve Communication to Help Ensure Timely 

Implementation of Air National Guard Recommendations. GAO-07-641. 

Washington, D.C.: May 16, 2007. 

Military Base Closures: Opportunities Exist to Improve Environmental 

Cleanup Cost Reporting and to Expedite Transfer of Unneeded Property. 

GAO-07-166. Washington, D.C.: January 30, 2007. 

Military Bases: Observations on DOD’s 2005 Base Realignment and 

Closure Selection Process and Recommendations. GAO-05-905. 

Washington, D.C.: July 18, 2005. 

Military Bases: Analysis of DOD’s 2005 Selection Process and 

Recommendations for Base Closures and Realignments. GAO-05-785. 

Washington, D.C.: July 1, 2005. 

Armed Forces Institute of Pathology: Business Plan’s Implementation Is

Unlikely to Achieve Expected Financial Benefits and Could Reduce 

Civilian Role. GAO-05-615. Washington, D.C.: June 30, 2005. 

Military Base Closures: Updated Status of Prior Base Realignments and

Closures. GAO-05-138. Washington, D.C.: January 13, 2005. 
Related GAO Products 

Military Base Closures: Assessment of DOD’s 2004 Report on the Need 

for a Base Realignment and Closure Round. GAO-04-760. Washington, 

D.C.: May 17, 2004. 

Military Base Closures: Observations on Preparations for the Upcoming

Base Realignment and Closure Round. GAO-04-558T. Washington, D.C.: 

March 25, 2004. 

(290622) Page 53 GAO-08-20 Armed Forces Institute of Pathology
GAO’s Mission The Government Accountability Office, the audit, evaluation, and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and policies; 

and provides analyses, recommendations, and other assistance to help

Congress make informed oversight, policy, and funding decisions. GAO’s 

commitment to good government is reflected in its core values of 

accountability, integrity, and reliability. 

The fastest and easiest way to obtain copies of GAO documents at no cost

is through GAO’s Web site (www.gao.gov). Each weekday, GAO posts 

newly released reports, testimony, and correspondence on its Web site. To

have GAO e-mail you a list of newly posted products every afternoon, go 

to www.gao.gov and select “E-mail Updates.” 

The first copy of each printed report is free. Additional copies are $2 each. 

A check or money order should be made out to the Superintendent of 

Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 

more copies mailed to a single address are discounted 25 percent. Orders 

should be sent to: 

U.S. Government Accountability Office 

441 G Street NW, Room LM 

Washington, DC 20548 

To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Gloria Jarmon, Managing Director, jarmong@gao.gov, (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, DC 20548 

Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800 

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, DC 20548 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Mail or Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

PRINTED ON RECYCLED PAPER