Military Base Realignments and Closures: Impact of Terminating, Relocating, or Outsourcing the Services of the Armed Forces Institute of Pathology
Published: 2007-11-09T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: On May 13, 2005, the Department of Defense (DOD) recommended closing  the Armed Forces Institute of Pathology (AFIP)—an agency within  DOD—as part of the Base Realignment and Closure (BRAC) process. 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. In addition to providing services to DOD, AFIP  provides its expertise to other physicians such as those working at the  Department of Veterans Affairs (VA) and it has statutory authority to  provide pathology services to civilian physicians. According to the College  of American Pathologists (CAP) and other pathology organizations, AFIP  is relied upon by its customers as a definitive consult on the most difficult- to-diagnose cases and through its research and training has advanced the  knowledge and competency of the medical profession.
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. In light of the BRAC provision specific to AFIP, 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, as well as those conducted by the Army Audit  Agency and BearingPoint—a consulting company that fulfilled a contract  from the Army Surgeon General to review AFIP. We also reviewed other  documents and legislation pertaining to AFIP and the BRAC provision,  including business plans and data related to analysis that led to BRAC- related decisions. Additionally, we obtained data from AFIP to describe  key services it provides and we determined the data to be sufficiently  reliable for the purposes of this report. We also interviewed officials from  AFIP, VA, the American Registry of Pathology (ARP), and pathology  associations such as CAP to collect information on the services that AFIP  provides. Within DOD, we interviewed officials from the Offices of the  Surgeons General of the Army, Navy, and Air Force; the Office of the  Assistant Secretary of Defense for Health Affairs (ASD(HA)); the  TRICARE Management Activity; the Office of the Deputy Under Secretary  of Defense (Installations and Environment); the Uniformed Services  University of the Health Sciences (USUHS)—a military medical training  and research institution; 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.
subsections: section_title: Background
paragraphs: 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.
subsections: section_title: Role of AFIP
paragraphs: Throughout the early part of the 20th century, AFIP was the only  institution in the country that maintained expertise in every major area of  anatomical pathology, attracting large numbers of consultations, trainees,  and research grants on the basis of the institute’s unique reputation.  However, according to AFIP’s Scientific Advisory Board, many changes in  modern medical practice over the last several decades have altered the  environment in which AFIP operates. For example, AFIP must now  compete with over one hundred civilian medical institutions, many of  which have in-house experts and comparable subspecialty areas of  pathology.
AFIP provides pathology expertise for all branches of the military. AFIP  also provides pathology expertise for VA in exchange for a specified  number of VA staff positions assigned to AFIP. Additionally, AFIP offers  pathology expertise on a reimbursable basis for its civilian customers. To  assist AFIP in this part of its mission, the Department of Defense  Appropriation Authorization Act for Fiscal Year 1977 authorized ARP to be  established as a nonprofit corporation with responsibility for encouraging  and facilitating collaborative work between AFIP and civilian medicine.  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. 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.
section_title: DOD Examines AFIP’s Future Role
paragraphs: 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. 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.
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. 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.
section_title: AFIP’s Key Services Include Consultation, Education, and Research That Benefit DOD, VA, and Civilian Communities
paragraphs: 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.
subsections: section_title: Providing Consultations Is AFIP’s Primary Mission, and DOD Is Its Most Frequent Customer
paragraphs: AFIP’s primary mission is to provide diagnostic consultations. Its  pathologists spend nearly twice as much time providing this service as  they do providing education and research services. AFIP pathologists  provide consultations for cases referred to them with and without  diagnoses. That is, when physicians—clinicians or general pathologists— at civilian, DOD, or VA medical centers cannot make a diagnosis or when  they are unsure of their initial diagnosis and are in need of another  opinion, they can send the case to AFIP’s subspecialty pathologists 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. In the course of  providing these diagnostic consultations to the requesting physicians,  AFIP receives and is able to add pathology material 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. 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.
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.)
In 2006, about 62 percent (25,621) of AFIP’s cases were for consultations  where AFIP pathologists reviewed the initial diagnoses from DOD, VA,  civilian, or other physicians for confirmation or change. For these cases,  AFIP pathologists changed the initial diagnoses from requesting physicians  in 10,987 cases, or about 43 percent of the time. For the remaining   57 percent of the cases (14,634), AFIP confirmed the requesting  physicians’ initial diagnoses. 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.
The type of consultations DOD, VA, and civilian physicians seek from  AFIP differ somewhat, both in terms of the number of cases sent without a  diagnoses and the type of pathology expertise requested. For example,   47 percent of DOD’s consultation requests were sent without an initial  diagnosis, compared to 27 percent from VA and 31 percent from civilian  physicians. This may be due, in part, to the type of expertise DOD and  civilian physicians most commonly need, which also differs. For example,  in 2006, almost a quarter of all DOD consultations were in the area of  forensic toxicology, which includes examining material from autopsies  and testing biological specimens for alcohol and drugs. However, VA  physicians most frequently requested AFIP’s environmental toxicology  diagnostic consultations, while civilian physicians most frequently  requested hepatic consultations—involving diseases of the liver—as well  as gastrointestinal consultations. The other consultation service most  frequently requested by DOD, VA, and civilian pathologists was for  dermatopathology—or the interpretation of skin biopsies.
section_title: AFIP Provides Varied Educational Services, Used Primarily by Civilian Physicians
paragraphs: 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. 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, and 5 percent were from VA. Most live CME courses are  attended predominantly by civilians. For example, in 2006, 96 percent of  the residents who attended the Radiologic-Pathologic Correlation course  were civilians. However, some courses are solely attended by military  health professionals because they involve issues specific to DOD or  because AFIP does not allow civilians to attend classes such as its Air  Force Medical Forensic Sustainment course. Overall, AFIP’s courses have  attracted instructors and students from around the world. In 2006,  individuals representing over 70 institutions, including the Federal Bureau  of Investigation, the National Institutes of Health, private academic  institutions and medical centers, and MTFs participated in AFIP’s CME  program.
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.
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, which DOD, VA, and civilian pathologists told us are a primary  reference source and serve as an important, frequently used tool as they  practice pathology. The fascicles are updated to capture the more recent  developments in pathology.
section_title: AFIP’s Research Benefits DOD, VA, and Civilians
paragraphs: 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. All outside researchers are required to  collaborate with an AFIP pathologist in order to access AFIP’s materials.
The repository contains over 3 million disease specimens and their  accompanying case histories dating back over 150 years. Because of the  large volume of cases in the repository, researchers can conduct studies of  considerable sample size. Since AFIP receives pathology material for many  difficult-to-diagnose diseases, the repository contains complex and  uncommon cases that have accumulated over time. Studying these  samples allows for advances in diagnosis and treatment of diseases. For  example, AFIP has accumulated a large collection of gastrointestinal  stromal tumors, a relatively uncommon tumor. Recent studies involving  this collection have led to advances in the identification of, and therapy  for, this tumor. One of the responsibilities of AFIP pathologists is to  classify the material that AFIP receives into the repository so that  researchers can access it in the future. As medical knowledge evolves,  AFIP pathologists reclassify material in the repository to better  characterize it for future use. AFIP staff are also in the process of putting  material from the repository in digital form to expand its use for research.
AFIP conducts and collaborates on research applicable to military  operations and general medicine, so its research affects DOD, VA, and  civilian communities. Although “militarily relevant” research has not been  well-defined, AFIP staff said it generally includes subjects of direct  interest to the military. For example, according to AFIP staff, research  conducted in collaboration with the Armed Forces Medical Examiner has  led to developments such as improved body armor and acute care of  wounded personnel. Further, AFIP conducts and collaborates on  infectious disease and cancer research, which has applicability for the  civilian community as well. AFIP’s infectious disease research has focused  on the characterization of potentially epidemic organisms, such as severe  acute respiratory syndrome, as well as on the development of improved  vaccines and the detection of biologic toxins, such as those that may be  used in biological warfare. AFIP’s cancer research, including breast,  gynecologic, and prostate cancers, has resulted in more accurate diagnosis  and development of better treatment methods. Table 3 provides examples  of AFIP’s research projects, including their impact.
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. AFIP  staff said that they began to focus on increasing militarily relevant  research and reducing DOD-funded civilian-focus research as early as  2001.
section_title: DOD Has Specific Plans to Terminate Most Services Currently Provided by AFIP and Is Developing Plans to Relocate the Others
paragraphs: 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. Once the reorganization plan  has been submitted, DOD can resume reorganizing and relocating AFIP.
subsections: section_title: Most of AFIP’s Services Will Be Terminated, but Some Will Be Relocated
paragraphs: DOD plans to terminate AFIP’s provision of diagnostic consultations and  outsource certain DOD diagnostic consultations to the private sector  through a newly established PMO. More specifically, the BRAC provision  requires that the PMO be established at the new Walter Reed National  Military Medical Center in Bethesda, Maryland, 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. 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  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 officials  in a November 16, 2006, memorandum that he had approved the retention  of four services—the DOD Veterinary Pathology Residency Program,  Automated Central Tumor Registry, Center for Clinical Laboratory  Medicine, and Patient Safety Center. He also informed them that the  remaining AFIP services would be disestablished unless any of the key  officials identified the need to retain specific services. Based on responses  from the key officials, an additional six AFIP services were recommended  for retention. As of September 2007, the ASD(HA) had not made a final  decision on them. These six services include diagnostic telepathology, two  biodefense projects, reserve biological select agent inventory, depleted  uranium (DU) testing, and cystic fibrosis testing. In addition, VA expressed  an interest in having DOD retain the DU testing capability. Table 4  summarizes AFIP services that will be relocated or established as  specified in the BRAC provision, those that were subsequently added by  the ASD(HA) to be retained, and those that were recommended for  retention by the DOD officials and are awaiting final decision. (See app. III  for a description of services currently performed by AFIP that are to be  retained and relocated, or newly established, or are awaiting final  decisions.)
section_title: Planned Implementation to be Completed by 2011
paragraphs: According to DOD’s most recently developed implementation plan,  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.
Implementation of these plans were put on hold by the requirements of  section 3702 of the fiscal year 2007 supplemental appropriations act,  which suspended all BRAC actions affecting AFIP until after DOD submits  detailed plans to the House and Senate Appropriations and Armed  Services Committees, which are due by December 31, 2007. DOD officials  acknowledge that the timeline as envisioned in their February 2007  implementation plan can no longer be met and the full amount of onetime  savings from disestablishment of AFIP will not be realized, although they  believe that they may still be able to complete all actions required by the  BRAC provision by 2011.
While DOD is required to share more information regarding its plans with  Congress before the end of the year, other developments could impact the  implementation of those plans. Specifically, on May 17, 2007, the House  passed H.R. 1585, a bill for the National Defense Authorization Act for  Fiscal Year 2008, which contains a provision that would require DOD to  establish a “Joint Pathology Center” at the National Naval Medical Center  in Bethesda. On October 1, 2007, the Senate passed its version of the same  bill. However, the Senate-passed version contains a provision that would  authorize, rather than require, DOD to establish a Joint Pathology Center  at Bethesda, “to the extent consistent with the final recommendations of  the 2005  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.
section_title: Closing AFIP May Have Minimal Effect, but Management Strategy Is Important to Address Key Challenges
paragraphs: 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.
subsections: section_title: DOD, VA, and Civilian Physicians May Be Able to Obtain Key Services from Other Institutions
paragraphs: In large part, DOD, VA, and civilian pathologists may be able to obtain  services elsewhere to replace those currently provided by AFIP.
Diagnostic consultations: Other medical institutions currently provide  diagnostic consultations that require subspecialty expertise. For example,  Massachusetts General Hospital (Boston, Massachusetts) and M. D.  Anderson Cancer Center (Houston, Texas) each provide about 60,000 or  more pathology consultations per year. While AFIP has many different  subspecialty areas, major civilian medical institutions, such as The Johns  Hopkins Hospital (Baltimore, Maryland) and Memorial Sloan-Kettering  Cancer Center (New York, New York) have from 10 to 17 different  subspecialty areas, respectively. Pathologists we interviewed emphasized  the importance of being able to obtain consultations from expert  pathologists, wherever they may work. They also stated that pathologists  with particular expertise who move from AFIP to the private sector may  be able to continue to provide consultations from whichever institutions  they may join. Most DOD and VA pathologists noted that even though  MTFs and VA medical centers can readily access AFIP consultations  without incurring additional fees, they already use subspecialty  pathologists from civilian medical institutions on occasion for  consultations due to their needs for particular subspecialty expertise and  concerns about obtaining a diagnosis in a timely manner. In addition, some  MTFs have subspecialty pathologists who can provide consultations for  other military physicians. For example, Brooke Army Medical Center and  Wilford Hall Medical Center—both located in San Antonio, Texas—each  have over seven different subspecialty areas. According to pathologists  from the five MTFs we interviewed, subspecialty pathologists from their  centers currently provide consultations to other nearby MTFs.
Pathology education: Other institutions also provide pathology  education. For example, CAP offers educational courses covering a range  of topics such as histotechnology and molecular pathology. DOD, VA, and  civilian pathologists that we interviewed told us that they have fulfilled  CME requirements through other institutions and could continue to do so.  Pathologists we interviewed said that DOD and VA pathologists generally  make independent decisions about which classes to attend and how to  meet accreditation requirements. Military pathologists we interviewed also  said that due to limited budgets, pathologists generally do not travel to  AFIP to attend courses because other pathology organizations, such as  CAP, offer CMEs that are accessible without the need to travel. Most DOD,  VA, and civilian pathologists we interviewed said that AFIP’s Radiologic- Pathologic Correlation course is unique and valuable to the radiology  profession. Some of the pathologists we interviewed said that this is  because the course utilizes the expertise of physicians who work with  pathology material from a large volume of difficult-to-diagnose cases,  requires attendees to bring unique specimens for class analysis and  discussion, and utilizes material from AFIP’s repository, which houses a  comprehensive collection of specimens. Further, many pathologists and  representatives from radiology organizations told us that it is the most  common way radiology residents fulfill a requirement to have specific  training in pathology. Although the course is recognized as being unique,  according to guidance set forth by the Accreditation Council for Graduate  Medical Education, radiologists could fulfill their accreditation  requirements through avenues other than AFIP. In addition, according to  DOD officials, it is not DOD’s mission to train civilian radiology residents,  although we believe that DOD could be in a position to assist outside  groups if any expressed interest in becoming responsible for maintaining  the course.
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.
section_title: DOD Faces Challenges in Ensuring That Military Physicians’ Access to Subspecialty Consultation Services Is Maintained at a Reasonable Cost
paragraphs: Given that AFIP is a central source that provides its customers with  definitive consults on the most difficult-to-diagnose cases, DOD and VA  pathologists face challenges in obtaining similar consultative expertise  once AFIP is disestablished. These challenges include determining how to  effectively use existing subspecialty pathology resources, obtain outside  expertise, and ensure coordination and funding of services to encourage  efficiency while avoiding disincentives to quality care. In addition, DOD  must decide whether VA could obtain consultation services through the  PMO and whether VA will be able to provide some subspecialty pathology  expertise for DOD. While DOD and VA officials have begun the process to  identify these challenges, as of mid-August 2007, they had not yet  developed management strategies to mitigate them.
Effective utilization of existing resources: While DOD officials told us  that they might be able to perform some in-house diagnostic consultations  for MTFs, they have not evaluated their existing medical resources to  determine the extent to which such consultation services can be  performed. According to DOD officials, some large MTFs have  subspecialty expertise and might be able to absorb some of the demand  for consultations, but DOD has not identified the potential volume and  type of consultations that these large MTFs could absorb. Further, DOD  pathologists expressed concerns that MTFs would not be able to absorb  many additional consultations without increasing the number of  subspecialty pathologists staffed at MTFs. This could be challenging, they  said, because it is difficult to retain pathologists within the military.  Because DOD is retaining some of its pathology capabilities from AFIP  under the BRAC provision, such as the Armed Forces Medical Examiner, it  will continue to have expertise available to provide services in the area of  forensic toxicology—DOD’s most frequently used consultation service in  2006. Further, several DOD officials were concerned that the DOD General  Counsel’s interpretation of the BRAC provision requiring outsourcing  through the PMO would preclude DOD from providing second-opinion  consultations from expertise within its MTFs. In addition, although VA  may be able to absorb some of its own consultations using its subspecialty  pathologists, including those who are currently assigned to AFIP, VA  pathologists told us that VA is limited in how many additional  consultations its current subspecialty pathologists could provide.
The PMO process: How the PMO functions and obtains diagnostic  services from medical centers outside DOD and VA has important  implications, both from a quality of care and a cost standpoint. DOD and  VA officials we interviewed indicated that DOD faces challenges in  developing the new PMO that can outsource for quality pathology services;  such challenges involve issues related to the timeliness of consultations  and the ability to obtain appropriate expertise at a reasonable cost. As of  August 2007, DOD has not formulated its management strategies for  addressing the following issues concerning how the PMO will function.
Assisting other federal agencies with obtaining consultations.
Although DOD has discussed the possibility that the PMO could include  VA in outsourced diagnostic consultations, no decisions had been made as  of mid-August 2007. Since VA has received over a quarter of AFIP’s total  consultations, VA officials have expressed an interest in continuing to  receive consultations through the PMO once DOD discontinues offering  AFIP consultations. VA officials also expressed concerns about the cost of  obtaining consultations outside of AFIP, which they estimated to be much  greater than the financial support it currently provides to AFIP for its  services. In addition, the officials stated that AFIP has been responsible  for VA’s DU program, 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  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  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.
section_title: Research Could Be Affected Depending on How DOD Plans to Populate, Maintain, and Use the Repository in the Future
paragraphs: 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. According to DOD, once that study is completed in October  2008, USUHS plans to convene a panel of experts to develop a blueprint on  how to use the repository for research, and then will likely contract for  development of a detailed plan on how to best populate, manage, and use  the repository. USUHS does not intend to finalize key decisions until that  process is complete.
USUHS officials told us that one of the challenges they face in the future is  how they will populate pathology material in the repository in order to  maintain its viability as a research tool. They explained that AFIP generally  populates its repository through pathology material obtained from its  consultation services. As a result, the repository includes material from  the DOD, VA, and civilian populations. Additionally, AFIP’s Radiologic- Pathologic Correlation course has historically contributed to the growth of  pathology material in the repository because students, who are primarily  civilians, are required to submit samples to AFIP that have pathologic  significance. We estimate that the repository gains approximately 1,200 to  2,400 samples per year from students attending this course. Pathologists  we interviewed explained that the value of the material in the repository is  related to the number of cases it accumulates for a particular disease. That  is, in order for a researcher to be able to identify the characteristic  patterns of a disease allowing for its diagnosis and treatment, there must  first be a sufficient number of cases of the particular disease. USUHS  officials told us that due to the large volume of cases that AFIP  accumulated in the repository, including complex cases, researchers can  currently conduct studies of considerable sample size. Thus, the manner in  which USUHS plans to continue to accumulate material in the repository  can influence the pace of research.
Because USUHS does not provide pathology consultations, in the absence  of civilian consultations it will need to develop other strategies to populate  the repository. The strategy that USUHS officials discussed with us was to  populate the repository with specimens from military hospitals. Populating  the repository in this manner, however, could skew the repository since  military hospitals generally draw patients that are largely young, male, and  active. This could decrease the usefulness of the repository, ultimately  affecting the breadth of research. As a result, it is important that USUHS  develop a strategy to determine how it will populate the repository,  considering both the quantity of pathology material for each disease as  well as the quality and type of material from which it draws.
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.
section_title: Conclusions
paragraphs: AFIP is a noted institution that has provided pathology expertise in a  range of subspecialty areas, and its customers value the services that it  provides. Congress has mandated that DOD provide a detailed plan on  disestablishing AFIP by December 2007, which gives DOD an opportunity  to address potential challenges involved with closing the facility. DOD  awarded a contract to study the usefulness of the material in the  repository, which it anticipates to be completed by the end of 2008. DOD  anticipates using the study, a subsequent panel of experts, and a possible  second contract to develop a detailed implementation plan to help make  decisions on how the repository will be managed. As part of its planning  process, it is critical for DOD’s plan to go beyond the steps to terminate,  relocate, or outsource AFIP’s services and include implementation  strategies that detail how it will organize consultation services and manage  the repository in the future. DOD has not yet developed these strategies— strategies that could help mitigate potential negative impacts of  disestablishing AFIP and facilitate a smooth transition as DOD looks to  other sources for obtaining high-quality pathology services.
section_title: Recommendations for Executive Action
paragraphs: 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.
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.
section_title: Agency Comments and Our Evaluation
paragraphs: DOD and VA provided written comments on a draft of this report, included  in appendix IV and appendix V. In commenting on a draft of this report,  DOD concurred with the report’s findings and conclusions and fully  concurred with our recommendation for DOD to include its  implementation strategies for organizing future pathology consultation  services in its December 2007 plan to the Congress. However, DOD  partially concurred with the recommendation to report to the Congress  within 6 months of completing its study on the viability of the repository.  Specifically, DOD indicated that USUHS would not be in a position to  report its strategies on managing the repository until further work was  completed. As a result, we modified our recommendation to limit the  reporting requirement to information on the viability of material in the  repository and its usefulness for research. We also added another  recommendation that DOD should report to Congress at a later date on  USUHS’s planned strategies for managing the repository. In its written  comments, VA agreed that the draft report was factually accurate, but  indicated that it did not fully capture the essential nature of AFIP’s  services to VA and DOD or fully address the impact of its closing. We  believe that we provided a balanced assessment of AFIP’s services and the  impact of its closing.
In its comments, DOD agreed with the description of the challenges it  faces in developing new approaches to obtaining pathology expertise  through the PMO and managing the repository to ensure that it remains a  rich resource for civilian and military research. DOD emphasized that it  was in the process of developing alternative strategies that would be  coordinated internally and with VA to ensure that the strategies would  meet DOD’s needs, assist the VA, and be in accordance with BRAC  recommendations. DOD concurred with our recommendation that the  Secretary of Defense should include in the December 2007 plan to  Congress implementation strategies for how DOD will use existing in- house pathology expertise available within MTFs, identify and obtain  needed consultations from subspecialty pathologists with appropriate  expertise through the PMO in a timely manner, and solidify the source and  organization of funds to be used for outsourced consultation services. In  addition, DOD agreed that the Secretary of Defense should submit a plan  to Congress within 6 months of completion of the repository evaluation  contract to provide information on the status of pathology material in it  and its research potential. However, DOD indicated that the results of the  evaluation contract will likely result in another contract to help develop a  detailed strategy on how USUHS will populate, manage, and use the  repository. Therefore, DOD will not be able to report on how USUHS will  populate, manage, and use the repository within 6 months of completion  of the repository evaluation contract and did not concur with that portion  of the draft recommendation. Given this, we modified our  recommendations in this report to reflect the steps DOD anticipates  taking. Specifically, we separated the recommendations to address  reporting on the viability of the repository material and the strategies for  its maintenance and use.
In commenting on a draft of this report, VA indicated that the report was  factually accurate, but did not sufficiently describe the potential impact  associated with closing AFIP. VA focused on five concerns—DU testing,  stagnation of the repository, difficulties in replacing AFIP’s consultation  services and obtaining them through the PMO, potential impact on patient  care, and the potential costs to replace existing services.
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.
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.  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   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.
section_title: Appendix I: Scope and Methodology
paragraphs: To describe key services that the Armed Forces Institute of Pathology  (AFIP) provides to the Department of Defense (DOD), the Department of  Veterans Affairs (VA), and civilian communities, we reviewed recent  reports describing AFIP’s services and business practices, including a  previous GAO report and an Army Audit Agency report on AFIP’s  business plan and a BearingPoint report on AFIP’s capabilities, 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.
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.
section_title: Appendix II: Maps of the Armed Forces Institute of Pathology’s (AFIP) 2006 Consultations
paragraphs: 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.)
section_title: Appendix III: Description of Services Performed by the Armed Forces Institute of Pathology (AFIP)
paragraphs: Appendix III: Description of Services  Performed by the Armed Forces Institute of  Pathology (AFIP)
Legal Medicine: Legal Medicine provides consultation, education, and  research on medical legal, quality assurance, and risk management issues  to the Department of Defense (DOD); manages a registry of closed DOD  medical malpractice cases; manages the DOD Centralized Credentials  Quality Assurance System; assists the Uniformed Services University of  the Health Sciences (USUHS) with the masters degree program in  Forensic Sciences; awards continuing medical education (CME) credits in  medical legal, quality assurance, and risk management to nurses and  physicians; and publishes the journals Legal Medicine and Nursing Risk  Management.
National Museum of Health and Medicine: The National Museum of  Health and Medicine was established during the Civil War as the Army  Medical Museum. The Museum promotes the understanding of medicine  from past, present, and future, with a special emphasis on American  military medicine. It has five major collections: Anatomical, Historical,  Otis Historical Archives, Human Developmental Anatomy Center, and  Neuroanatomical, which are estimated to contain more than 24 million  objects.
Repository: The National Pathology Repository contains approximately   3 million case files and associated paraffin blocks, microscopic glass  slides, and formalin-fixed tissue specimens. Tens of thousands of cases are  added to the repository each year. Staff code all material for future  research use.
The Office of the Armed Forces Medical Examiner, DNA  (deoxyribonucleic acid) Registry, and Accident Investigation: The  Office of the Armed Forces Medical Examiner conducts scientific forensic  investigations for determining the cause and manner of death of members  of the Armed Forces and of civilians whose deaths come under exclusive  federal jurisdiction. The office provides consultative services in forensic  pathology, forensic toxicology, forensic anthropology, and DNA  technology, as well as on-site medical legal investigations of military  accidents. It is the only federal resource of its kind, so other federal  agencies frequently use its services. The DOD DNA Registry is at the  forefront of nuclear and mitochondrial DNA technology, supports the  Office of the Armed Forces Medical Examiner in identification, and serves  as the repository for specimens obtained from military personnel to be  used for identification.
Enlisted histology technician training: The Tri-Service School of  Histotechnology is the only military histopathology training program,  according to a DOD official. It consists of 180 training days in the technical  operations of anatomic pathology. Training includes instruction in the  theory and application of histotechnology and practical training in the  fixation, processing, embedding, microtomy, and staining of tissue  specimens prior to examination by a pathologist. The curriculum also  includes instruction and practical experience as a postmortem  examination (autopsy) assistant.
Program Management Office (PMO): The PMO will be newly  established to coordinate pathology results, contract administration, and  quality assurance and control of DOD second-opinion consults worldwide.
DOD Veterinary Pathology Residency Program: The DOD Veterinary  Pathology Residency Program is a 3-year postdoctoral training program.  Residents are involved in consultation, education, and research during the  program. The residency culminates in a 2-day examination given by the  American College of Veterinary Pathologists, and successful completion of  this examination results in board certification in veterinary anatomic  pathology.
Automated Central Tumor Registry: The Automated Central Tumor  Registry provides the uniformed services MTFs with the capability to  compile, track, and report cancer data on DOD beneficiaries. The  objective of the registry is to maintain a research quality database for  cancer reporting that supports outcome analysis, referral patterns, trend  analysis, statistical reporting, health care analysis, epidemiology, and  uniform data collection and tracking.
Center for Clinical Laboratory Medicine: The Center for Clinical  Laboratory Medicine directs the operation of the DOD Clinical Laboratory  Improvement Program, as defined by DOD Instruction 6440.2 and Public  Law No. 100-578; administers law and federal policy for military medical  laboratory operations in peace, contingency, and wartime, ensuring that  no restrictions or cessation of laboratory services impedes DOD mission  requirements; and acts as gatekeeper for DOD and Centers for Disease  Control and Prevention (CDC) initiatives to develop a biological warfare  detection and response system, that is, National Laboratory Response  Network.
Patient Safety Center: The Patient Safety Center manages a  comprehensive patient safety data registry for DOD. The DOD Patient  Safety Registry is a database that gathers standardized clinically relevant  information about all instances and categories of actual events and close  calls. This registry is used to identify and provide feedback on systemic  patterns and practices that place DOD patients at risk, and thereby it  stimulates, initiates, and supports local interventions designed to reduce  risk of errors and to protect patients from inadvertent harm. The Patient  Safety Center publishes DOD Patient Safety Alerts, and it produced the  first Patient Safety Toolkit targeting patient fall reduction.
Diagnostic telepathology: The practice of pathology involves using  telecommunications to transmit data and images between two or more  sites remotely located from each other, according to a DOD official. The  data include clinical information about the patient, such as signs,  symptoms, treatment, and response; gross description of the surgical  specimen(s); and digital images of the processed specimen. These data are  transmitted electronically, allowing a pathologist practicing in a  geographically distant site to consult another pathologist for a second  opinion, or to consult other pathologists who are experts on particular  disease processes.
Biodefense Project – The Joint Biological Agent Identification and  Diagnostic System: The Joint Biological Agent Identification and  Diagnostic System pertains to a rapid identification and diagnostic  confirmation of biological agent exposure or infection, according to a  DOD official. The standalone system consists of a portable unit to perform  sample analysis, a laptop computer for readout display and assay reagent  test kits to identify multiple biological warfare agents, infectious disease  agents, and biological toxins.
Biodefense Project – The Critical Reagent Program: The Critical  Reagent Program provides bulk quantities of DNA extracted from selected  biological threat agents, according to a DOD official. These are then used  to develop validated, high-quality immunological and DNA-based  biodetection reagents to support different biological warfare agent  detector platforms.
Reserve Biological Select Agent Inventory: The Reserve Biological  Select Agent Inventory is registered with CDC and with the Army Medical  Command, and includes over 1,500 strains of controlled biological select  agents and toxins, according to a DOD official. These are stored in freezers  in secure Biosafety Laboratory level 3 areas of AFIP. Storage, use, and  transfer of any agents or toxins is strictly controlled and regulated by CDC  and Army regulations.
Depleted uranium (DU) testing: DU Urine Testing supports medical  surveillance programs by measuring the levels of uranium in patients’  urine and identifies the specific source of exposure by accurately  measuring uranium isotopic ratios, according to a DOD official. DU  Testing in Body Fluids and Tissue provides chemical analysis of embedded  DU fragments in tissues removed from shrapnel wounds.
Cystic fibrosis testing: A test for cystic fibrosis is one of several tests for  genetically inherited diseases that are recommended by the Department of  Health and Human Services’ Health Resources and Services  Administration and the American College of Medical Genetics. AFIP  ceased cystic fibrosis testing on June 1, 2007. All DOD cystic fibrosis tests  are currently being performed by commercial labs or other DOD labs.
section_title: Appendix IV: Comments from the Department of Defense
section_title: Appendix V: Comments from the Department of Veterans Affairs
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: 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.
section_title: Related GAO Products
paragraphs: 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.
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.