The Department of Defense (DOD) has about 13,700 active duty physicians, nearly 1,300 of whom entered military service in fiscal year 1994. About 93 percent of these new physicians entered the military through the Health Profession Scholarship Program (HPSP) or through DOD’s medical school—the Uniformed Services University of the Health Sciences (USU)—which were authorized as complementary programs under the Uniformed Services Health Profession Revitalization Act of 1972 (P.L. 92-426.) To acquire physicians through these two programs, DOD incurs either the costs of providing the participants a medical education plus student stipends for scholarship participants or military salaries and benefits for students at the University. After the participants graduate from medical school, DOD incurs the costs of physician ownership—providing graduate medical education (GME) and other training; salaries, bonuses, and benefits; and retirement pay for those physicians who remain on active duty for at least 20 years. Military physicians are needed to support operational forces during war or other military operations and to maintain the well-being of the forces during nonoperational periods. Military physicians also provide health care services to nonactive duty beneficiaries. With the end of the draft in 1972, the military services needed new means of obtaining active duty physicians. To address this need, Public Law 92-426 established two complementary accession sources—the scholarship program and the University. In addition to these sources, the services continue to attract physicians directly from the private sector.Table 1.1 shows the number of physicians entering each military service from each accession program for fiscal years 1992 to 1994. The scholarship program is the largest source for military physicians. The legislative history of Public Law 92-426 indicates that the scholarship program was intended to provide the services with the majority of their physicians, most of whom would not be expected to make the military a lifetime career. Under the scholarship program, the services pay medical school tuition and fees as well as stipends for civilian medical school students. In return, after graduation, program participants must serve 1 year of active duty military service for each year that they receive benefits with a 2-year minimum obligation. Scholarship program participants also incur an obligation to serve in the reserves for a period of time, which varies depending upon the number of years of benefits received. The total obligation of active and reserve duty is 8 years for all scholarship program participants (not including time spent in GME). Upon graduation, most scholarship program participants enter active duty at the O-3 pay grade (that is, as captains in the Army and Air Force and as lieutenants in the Navy) and begin their first year of GME in military medical facilities. Licensure typically occurs at the end of that year. At that point, depending upon the needs of the service, a scholarship program participant may continue GME or begin serving as a general medical officer. Time spent in GME does not satisfy the commitment incurred as a participant in the scholarship program; however, such time is credited for retirement purposes. Although most scholarship program participants enter active duty upon graduation from medical school, others are granted a deferment so that they may pursue GME in the civilian sector. Upon completion of their GME, deferred scholarship program participants serve their active duty obligations, entering active service at the pay grade they would have attained had they not deferred their military service. Of the 987 scholarship program participants who graduated in fiscal year 1994, 283 were deferred. Scholarship program participants who participate in military GME programs are referred to as regular scholarship program participants. In fiscal year 1994, 704 regular scholarship program participants entered the military. For DOD, the educational costs of acquiring physicians through the scholarship program include medical school tuition and fees, student stipends, active duty pay for a 45-day period each year, and program administration costs. After graduation, the costs that DOD incurs to employ these physicians include those for GME (for those graduates who participate in military GME programs); initial medical readiness training (including basic officer training); salary, bonuses, and benefits; and retirement pay for those physicians who remain on active duty for at least 20 years. The University also authorized by Public Law 92-426, is DOD’s medical school in Bethesda, Maryland. According to the legislative history, the University is intended to provide DOD a group of military physicians likely to make the military a career. When students enter the University’s School of Medicine, they begin active military service with the pay grade of O-1 (that is, as second lieutenants in the Army and Air Force or ensigns in the Navy) and receive all benefits associated with active military service. Upon graduation, University students are promoted to the grade of O-3 and begin serving a 7-year obligation. They might also incur a reserve obligation of 2 to 6 years (not including time spent in GME). On average, the University has enrolled about 160 students each year since 1981. Most graduates go into the Army, Navy, or Air Force; however, a limited number of students each year are sponsored by the Public Health Service. For example, of the 155 graduates in 1994, 8 were sponsored by the Public Health Service. Since its first class graduated in 1980, the University has produced 2,064 physicians for the three services and 84 for the Public Health Service. For DOD, the educational costs of acquiring physicians through the University include the costs of student and faculty salaries and benefits, facility operations and maintenance, and basic officer training. After students graduate, DOD incurs the costs of their GME, salary and benefits, and retirement pay for those who serve at least 20 years. Military medicine is not a recognized medical specialty; however, medical literature we reviewed as well as military and civilian officials with whom we spoke identified a number of factors that differentiate the practice of military medicine from the practice of medicine in civilian settings. According to these sources, the primary factors that contribute to the special needs of military medicine are the objectives of the combat medical care system, the circumstances and environments in which care is provided, and the need to understand military operations and procedures. However, no consensus exists in DOD or the services regarding the amount or types of education and training physicians need—in addition to traditional medical education—to meet the special needs of military medicine. Chapter 3 discusses how University and scholarship program graduates are prepared for the special needs of military medicine. Practitioners of military medicine concentrate their attention on preventing and treating illnesses and injuries more commonly experienced in operational or combat settings. While similar or related illnesses, injuries, or health concerns exist in civilian settings, military medical literature and practitioners state that some illnesses and injuries lack parallels in civilian settings; thus special training is necessary to practice medicine in operational settings in support of combat and noncombat missions. Military medical literature notes that the objectives of the combat medical care system are different from civilian objectives. In civilian circumstances, the physician’s objective is to ensure the welfare of the individual patient. In contrast, the objective of the military physician is to “conserve the fighting strength” in order to ensure the success of the military mission. To minimize troop losses to disease and injury both before and during deployment, the military physician is responsible for identifying the health threats to which troops are exposed and developing plans to minimize their impact. Such preventive medicine programs include immunization, sanitation, and safety awareness. When troops become ill or are injured in combat, the objective of military physicians is to provide treatment that will permit the patient’s return to duty, if possible, or removal of the patient to a location where additional care may be provided. To accomplish this objective, the combat medical system is organized into echelons, or different levels of medical support for combat troops. Echelon 1, the most far-forward and mobile level of medical support, is necessarily the most austerely staffed and equipped. At this level, minimally injured personnel are treated and returned to combat. More serious casualties are evacuated to higher echelons. Each echelon, 2 through 5, has all the capabilities of the lower echelons, plus increasingly sophisticated capabilities. An essential element of the combat medical system is the practice of triage, or sorting, which is based on the principle of accomplishing the greatest good for the greatest number under the circumstances. Triage is the process of establishing the priorities for treatment and evacuation and is necessary in the case of mass casualties in order to avoid overwhelming the medical resources available. In such instances, before providing treatment, medical personnel are required to place casualties in categories ranging from urgent (those injuries requiring immediate intervention to prevent death) to expectant (wounds so severe that survival would be unlikely even if all medical resources were applied.) In operational settings, the military physician serves as medical staff advisor to the commander. In so doing, the physician participates in the development of command plans and policies, advises the commander on relevant medical issues, and works with other staff officers to ensure medical support of military operations. Given these responsibilities, military physicians need an understanding of military operations, staff planning and administration processes, the various work environments, and the natural and manmade hazards that personnel may encounter. Even before its first class enrolled in 1976, the University was controversial. Several earlier studies have concluded that the University is the most costly source of obtaining military physicians. Consequently, proposals have been made to close the University, including one that resulted from the work of the National Performance Review (NPR). The National Defense Authorization Act for Fiscal Year 1995 specifically prohibited the closure of the University and directed us to report on issues related to the University and other sources of military physicians. The act directed us to report on various aspects of physician accession programs including costs, retention rate patterns, quality of medical education, and preparation for the special needs of military medicine. The act also directed us to report on actions taken by the University in response to recommendations made in 1990 by DOD’s Inspector General concerning internal controls and other issues. To respond to these issues, we collected information (through interviews and documentation) from the following organizations and officials: the Office of the Assistant Secretary of Defense (Health Affairs); the Uniformed Services University of the Health Sciences; the Joint Staff; the Offices of the Surgeons General of the Army, Navy, and Air Force; • medical readiness training representatives for each service; • major medical units throughout DOD; the Office of Management and Budget; the Congressional Budget Office; the American Medical Association; the Association of American Medical Colleges; and • various other organizations within and outside of DOD. A detailed discussion of our methodology is presented in appendix I. The results of our cost analysis are presented in chapter 2. Chapter 3 discusses the quality of medical education obtained by military physicians and how physicians from each accession source are prepared to meet the special needs of military medicine. Chapter 4 provides information on the activities conducted at the University in addition to its School of Medicine. Chapter 5 provides information on issues related to the retention of physicians. Chapter 6 presents overall conclusions about military physician accession programs and related issues. Appendix IV discusses the responses to the 1990 recommendations of DOD’s Inspector General. Our work was conducted between September 1994 and August 1995 in accordance with generally accepted government auditing standards. Our review of the costs of obtaining and retaining physicians for the military focused on the historical educational costs for the graduating class of 1994 and the projected postgraduation costs for additional training (including GME and initial medical readiness training), salary, and retirement costs. We analyzed prior studies and held discussions with military and civilian officials to identify the factors to include in our analysis. Our analysis showed that when considering DOD costs, the University is the most expensive source of military physicians. In a supplemental analysis, which includes an estimate of additional federal support for medical education, the University is the most expensive on a per graduate basis but comparable in cost to other accession sources when physician costs are distributed over the expected lengths of their military careers. In developing our analysis of University and scholarship program costs, we made decisions regarding the following key factors: the appropriate year to use as the base year for analytical purposes, the appropriate units of analysis against which to compare the estimated costs for each program, the use of retention rate data in the cost equations, and the appropriate methods of treating various components of each program’s costs. Each factor is discussed below with particular reference to the differences in approaches used by the Office of the Assistant Secretary of Defense, Program Analysis and Evaluation (PA&E), and the University in their analyses of the costs of obtaining physicians for the military. The University’s study, which responds to the issues that we were asked to address in the National Defense Authorization Act for Fiscal Year 1995, concluded that the scholarship program (as a combined program) is almost 2 times more costly than the University. The DOD study concluded that the University was 20 to 27 percent more costly than the regular scholarship program and 39 to 63 percent more costly than the deferred scholarship program, depending on medical specialty. Our review focused on the historical educational costs for the graduating class of 1994 and the projected costs for additional training and career compensation as expressed in 1994 constant dollars. Our focus on a specific graduating class represents a snapshot of the cost factors as they existed at the time of our analysis and can provide a benchmark for later analyses. The University’s analysis is also based on the 1994 graduating class; however, the PA&E analysis was performed in 1991 using 1989 data. PA&E used the number of expected years of service for the graduates of each program as the measure of benefit and the estimated cost per expected year of service as its unit of analysis. The University used the number of years of obligation for the graduates of each program as the measure of benefit and the cost per year of obligation as its unit of analysis. We used the PA&E unit of measurement and analysis (expected years of service) and the costs per graduate from each program as an interim unit of analysis. We believe that the University’s focus on the minimum obligation period understates each program’s contribution to military medicine because some graduates from all accession programs are retained longer than the minimum obligation period, including some who stay to retirement. For example, under the University model, the 155 graduates from its class of 1994 are expected to provide 1,085 staff years of service based on a 7-year obligation. For the scholarship program, the University model uses a 4-year obligation, which results in 2,816 expected staff years of service for the regular scholarship program and 1,132 for the deferred scholarship program. Table 2.1 shows our calculation of expected years of service for 1994 graduates of the University and the scholarship program using DOD physician retention projections. The selection of the expected years of service as our unit of analysis required that we use physician retention data in our calculations. Since 1981, DOD has maintained an electronic database on the rates at which physicians leave or stay in the military. The retention database identifies the program through which physicians are obtained, the military department, and the percentage of physicians remaining each year. DOD makes projections about (1) the average years of service that may be anticipated from physicians and (2) the percentage of physicians expected to stay in the military to retirement from each accession source. DOD’s projections are based on historical retention data for each program and the experience of all military physicians. DOD officials acknowledged that their retention database has not been updated since 1993. However, DOD and service officials agreed that DOD’s projections using this database are the best DOD-wide information available on the retention of military physicians. We used DOD’s retention projections to calculate the expected staff years of service for each accession source by multiplying the actual number of graduates from each program by the expected years of service for graduates from each program. We also calculated projected career compensation (salary and bonuses) and retirement costs using the DOD physician retention data. PA&E examined the costs of procuring and retaining physicians from medical school through retirement. PA&E’s cost elements included the University’s budget, educational costs for the scholarship program, military GME costs, salary and bonuses during a physician’s career, and estimates of physician retirement benefits. The University’s methodology focused on its operational budget and scholarship program educational costs, but excluded the other DOD costs associated with training and retaining physicians used in the PA&E model. We used the PA&E cost elements when considering DOD’s costs. DOD incurs costs for military physicians after they graduate from medical school—including the University—because of medical and military training requirements and to pay salaries and benefits during the military physician’s career. Under our calculation, educational costs represent about 9 percent of DOD’s total costs for the regular scholarship program, about 17 percent for the University, and about 19 percent for the deferred scholarship program. The total University budget in any year includes funding for activities that do not directly contribute to the education of a medical student. For example, in fiscal year 1994, the University budget included $28.5 million for projects, such as research on head and neck injuries, and the Armed Forces Radiobiological Research Institute. DOD and University officials agreed that these costs should not be included because they are not associated with the education of physicians. However, the University excluded an additional $18.6 million from its analysis for cost-avoidance activities. These are largely faculty and staff activities that the University believes DOD would continue to procure even if the University is closed, but at potentially higher costs. We have not included the University’s reductions for cost avoidance because our methodology focused on the actual outlays for the educational costs of the University and the scholarship program. Moreover, we were unable to validate the details in the University’s cost avoidance estimates. The University included additional federal contributions to civilian medical education (and by extension to the scholarship program) in its analysis, while the PA&E study did not. Considerable debate exists about whether other (non-DOD) federal support for medical education should be considered in the cost of obtaining military physicians. Authors of previous cost studies have argued that inclusion of these funds is inappropriate because this funding is made to civilian schools for reasons totally unrelated to the scholarship program. Counterarguments suggest that other federal support should be attributed to the scholarship program because civilian medical schools require this federal support to continue their operations. If other federal expenditures for the education of scholarship program students are included in the analysis, only a portion of these costs should be viewed as related to their careers as military physicians. For example, deferred scholarship program graduates serve about 5.29 years in the military on average and many more in the private sector. Nonetheless, because of the interest in some quarters for inclusion of other federal costs, we developed a supplemental analysis including, as a subsidy to the scholarship program, Department of Health and Human Services funding to civilian medical schools for research and GME programs (commensurate with the rate of scholarship program participation in civilian undergraduate and graduate medical education programs). In an effort to ensure comparability between the cost elements in the programs, we also included other federal dollars to the University in the form of research grants and support for its graduates who participated in civilian GME programs. Additional details about our cost methodology are in appendix I. Our analysis of DOD’s costs to educate and retain a military physician showed that the University is more costly than the scholarship program on a per graduate and an expected year of service basis. To illustrate: • DOD’s educational costs per graduate were $566,506 for the University and $125,946 for the scholarship program;• DOD’s educational costs per expected year of service were $30,697 for the University, $12,916 for the regular scholarship program, and $23,825 for the deferred scholarship program; • DOD’s total per graduate costs were $3.3 million for the University, $1.5 million for the regular scholarship program, and $0.7 million for the deferred scholarship program; and • DOD’s total costs per expected year of service were $176,236 for the University, $149,969 for the regular scholarship program, and $124,801 for the deferred scholarship program. Our supplemental analysis showed that when an estimate of additional federal dollars that support civilian medical education is included in the analysis, the University is more costly on a per graduate basis, but on an expected year of service basis, the University is nearly equal the cost of the regular scholarship program and less costly than the deferred scholarship program. To illustrate: the total cost per graduate, when all federal costs are included, was $3.4 million for the University, $1.8 million for the regular scholarship program, and $1.2 million for the deferred scholarship program; and the total cost per expected year of service, when all federal costs are included, was $181,575 for the University, $181,169 for the regular scholarship program, and $231,501 for the deferred scholarship program. The medical educational costs associated with the University include facility operations and maintenance, research and development, procurement, construction, and military and PHS salaries for faculty and students. Educational costs associated with the scholarship program include medical school tuition and fees, stipends and salaries for students, summer training, and program administration. The DOD cost to educate the 1994 graduates of the University was $566,506 per graduate—4-1/2 times as great as the cost to educate a medical student through the scholarship program ($125,946). The difference in cost between the University and the scholarship program narrows when education costs are amortized over the expected length of service for each group. DOD estimates show that physicians from the University are expected to serve nearly twice as long as their regular scholarship program peers and more than three times as long as deferred scholarship program physicians. Using DOD estimates that, on average, physicians from the University will serve 18.45 years; regular scholarship program physicians 9.75 years; and deferred scholarship program physicians 5.29 years, our calculation of the educational cost per expected year of service for University graduates was $30,697. Costs per expected year of service for University graduates are more than twice those for regular scholarship program participants ($12,916) who begin active military service immediately after graduation and 29 percent higher than the per expected year of service cost for scholarship program participants ($23,825) who defer their military service to attend GME in civilian institutions. Table 2.2 compares DOD’s educational costs for University and scholarship program physicians who graduated in 1994 on a per graduate and per expected year of service basis. Regular scholarship program participants and most University graduates receive additional medical training through GME programs primarily in DOD’s medical treatment facilities. DOD’s most current study of its military GME costs (based on 1992 data) estimated the annual GME cost per participant at $168,777, including resident salaries. Assuming an average of 4 years of GME for each participant, the GME per participant cost is $521,048, after adjusting for inflation. (Military GME costs do not apply to deferred scholarship program or University graduates who participate in civilian GME programs.) While the GME costs on a per participant basis are identical for the University and the regular scholarship program, the per graduate costs differ because the University costs are spread over all its graduates (155), even though 6 University graduates participate in civilian GME programs. GME costs for those 6 University graduates and all deferred scholarship participants are included in “non-DOD federal dollars”, as discussed on page 31. Table 2.3 shows our projections of DOD’s GME costs for University and regular scholarship program physicians who graduated in 1994. In addition to their graduate medical education, military physicians are required to have basic officer training, regardless of their accession source. In general, new scholarship program physicians also attend the Combat Casualty Care Course to acquire basic field medical skills. (University graduates generally do not attend the Combat Casualty Care Course.) Our projected costs (based on DOD estimates) of these training courses for the physicians who graduated in 1994 are shown in table 2.4. In addition to the cost of medical education, DOD bears physician retention costs, including career salary and bonuses, as well as retirement benefits. Compensation costs are estimated to be highest for graduates of the University because, on average, they are expected to remain in the service longer and to earn retirement benefits at a rate higher than either their deferred or regular scholarship program peers. Active duty compensation for physicians includes regular pay and allowances as well as special pay and bonuses that vary depending upon board certification status, length of service, and other factors. Because University graduates will be compensated over a greater number of years than their scholarship program peers, the per graduate compensation costs are estimated to be the highest for University graduates. Deferred scholarship program graduates earn nearly as much on an expected year of service basis because they enter active duty service after becoming fully trained in a medical specialty and, thus, receive higher compensation for the fewer years they serve. University and regular scholarship program graduates receive lower salaries while in military GME programs than they earn after their GME training, which reduces their average career earnings on an expected year of service basis. Table 2.5 shows the estimated costs of salary and bonuses for the University and scholarship program physicians who graduated in 1994. Military physicians are eligible for retirement benefits after 20 years of active military service. Because the University graduated its first class only 15 years ago, actual retirement data are not available. However, based on experience with other military physicians, DOD estimates that about 50 percent of the 1994 University graduates will remain on active duty through retirement, compared with 3 percent for deferred scholarship program graduates and 11 percent for regular graduates. Because the expected retirement rate for University graduates is higher than their scholarship program peers, projected retirement costs for physicians who graduated in 1994 are correspondingly higher for the University, as shown in table 2.6. Table 2.7 summarizes DOD costs for educating and retaining military physicians. Beyond the costs to DOD, a portion of the federal dollars that support undergraduate and graduate medical education may be considered as part of the overall cost of educating military physicians. For example, one form of federal support for undergraduate medical education is research funding through the National Institutes of Health ($5.7 billion in 1994) and other federal agencies. Similarly, a portion of the federal dollars that support civilian GME through the Medicare program ($6.2 billion in 1994) may be considered relevant to the overall cost of educating physicians from the deferred scholarship program and the University (six Public Health Service graduates from the University’s class of 1994 are participating in civilian GME programs). Table 2.8 shows our estimate of these costs. When all federal costs are included on a per graduate basis, our analysis shows that at a cost of $3.4 million, the University is about 1.9 times more expensive than the regular scholarship program ($1.8 million) and more than 2.7 times more expensive than the deferred scholarship program ($1.2 million). However, when total federal costs are spread over the expected life of a physician’s military career, the University is more comparable in cost to the other accession sources at $181,575 per expected year of service. The deferred scholarship program is the most expensive source using this approach at $231,501, while total federal costs for the regular scholarship program total $181,169 on an expected years of service basis. Table 2.9 summarizes total federal costs for obtaining and retaining military physicians. Our analysis shows that the University’s School of Medicine provides a traditional medical education that compares well with other U.S. medical schools and combines that education with coverage of topics more specifically related to the practice of military medicine. Traditional measures of quality place the University’s program within the midrange of medical schools nationwide and its graduates at or above other military physicians. The commanders of military medical treatment facilities that we contacted regard physicians who are graduates of the University as at least as well-prepared as their civilian-educated colleagues for the practice of medicine in the clinical setting. Our analysis shows that the University also provides students more exposure to the special needs of military medicine. Also, the medical commanders believe that the University’s approach produces physicians who at least initially are better prepared than their civilian-educated peers to meet the demands of military medicine. However, no conclusive evidence exists to show that University graduates are better prepared to meet DOD’s operational needs. Indicators generally accepted in the medical community show that the University provides the military services with physicians whose medical education is equivalent in quality to the education received by other military physicians. The University’s School of Medicine is fully accredited and its students have undergraduate grade point averages and admission test scores that fall within the midranges for such statistics for all medical schools. Postgraduate measures such as pass rates for the medical license examination and graduates’ performance in their first year of GME indicate that University graduates are equivalent to or slightly better than other military physicians. Most medical schools in the United States are accredited by the Liaison Committee on Medical Education (LCME), a joint activity of the Association of American Medical Colleges (AAMC) and the Council on Medical Education of the American Medical Association. In April 1993, LCME awarded the University full accreditation for 7 years, the standard length of time. LCME also identified areas for improvement during the accreditation process, including an overly dense curriculum (particularly for students’ first 2 years) and vacancies in several department chairs. In February, 1995, LCME notified the University of its satisfaction with the University’s progress in making improvements in these areas. For example, in response to the concerns raised about the density of its curriculum, modifications were made to the curriculum of the basic sciences to allow an afternoon of self-study in most weeks for first and second year students. In addition, four of the five vacant faculty chairs were filled. However, in June 1995, the position of the Dean of the School of Medicine became vacant and, as of September 1995, the School was seeking a permanent Dean. In addition to LCME’s accreditation of the School of Medicine, the University, as a whole, has been accredited by the Commission on Higher Education of the Middle States Association of Colleges and Schools, an organization that accredits institutions of higher learning. In the medical community, the academic credentials of the students that a medical school attracts are considered to be a reflection of the school’s quality. Two widely used measures of academic achievement among medical school applicants are undergraduate grade point averages (GPA) and scores on the Medical College Admissions Test (MCAT). Compared with their peers nationwide, students who entered the University in the fall of 1994 had above average MCAT scores. In addition, the MCAT scores of students at the University were higher than those for the Army and Navy scholarship program participants who entered in 1994. Figure 3.1 shows these averages. In contrast, Figure 3.2 shows that University students had average undergraduate GPAs that were slightly below the national average, higher than Army scholarship program entrants, and equivalent to Navy scholarship program entrants. University graduates compare favorably with other medical school graduates in their performance on the United States Medical Licensing Examination (USMLE) and in their evaluations from internships at military medical treatment facilities. Military medical commanders believe that University graduates perform as well or better clinically than other military physicians. DOD data indicate that University graduates are cited for fewer adverse clinical privileging actions than other military physicians. All students seeking medical licensure take the three steps of the USMLE, administered by the National Board of Medical Examiners. Part 1 tests the student’s ability to apply knowledge of the basic biomedical sciences, part 2 assesses the student’s application of clinical capabilities under supervision, and part 3 measures the candidate’s use of medical knowledge deemed appropriate for the unsupervised practice of general medicine. The most recent University class to have completed all three parts of the USMLE is the class that graduated in 1993. Those students took parts 1 and 2 while at the University and part 3 during their internship, scoring near the national average for all medical students and achieving pass rates that were equal to or better than the pass rates for all medical students, as shown in table 3.1. The classes that graduated in 1994 and 1995 had completed only parts 1 and 2 of the examination at the time of our review. The results of those tests are shown in table 3.2. The three military services operate GME programs. During the internship (the first year of GME), physicians are evaluated 13 times. We reviewed the evaluations for all interns at the Air Force’s Malcolm Grow Medical Center, the Walter Reed Army Medical Center, and the Bethesda National Naval Medical Center for the academic year 1993-94. On average, for the sample we reviewed, interns who graduated from the University received similar or higher evaluations than interns who graduated from other medical schools, as shown in table 3.3. “The graduates of demonstrate the same spectrum of abilities and clinical aptitude as the graduates from any of our best civilian medical institutions. I have seen no difference in intellect or performance.” “The graduates are of a more consistent level of quality a spectrum of abilities that come from the variety of civilian medical school sources.” DOD tracks adverse clinical privileging actions as an indicator of the performance of military physicians. Adverse clinical privileging actions can involve a range of activities such as malpractice, drug abuse, or unprofessional conduct. Based upon our analysis of data maintained by the Armed Forces Institute of Pathology, physicians who graduated from the University have had fewer reported adverse clinical privileging actions than military physicians from other sources. From 1982 to 1994, University graduates had 19 reported actions, or 1.48 actions per 1,000 physician staff years. During that same period, physicians from the scholarship program had 234 actions, or 3.06 actions per 1,000 physician staff years. Preparing physicians for the special needs of military medicine involves education, training, and experience beyond that of a traditional medical education. This additional preparation is broadly referred to as medical readiness training. Our analysis shows that the medical readiness training provided to University medical students is more extensive than that initially given to other military physicians in terms of the amount of time involved and the nature of the training. Leaders in military medicine that we contacted consider University graduates to be better prepared for military medicine, at least during the early years of their careers. However, University and DOD officials do not know of any objective evidence that shows that the extensive readiness training at the University produces physicians who are better prepared than their peers to meet the special needs of military medicine. Military physicians currently receive their initial readiness training through one of two means: University medical school students receive medical readiness training as part of their 4-year medical education; graduates of civilian medical schools receive it by attending medical readiness training courses that the services offer individually or jointly. The medical readiness training given to University medical students is more extensive in volume and breadth than the initial medical readiness training for other physicians. According to University officials, the University’s curriculum is intended to provide the medical and military knowledge and capabilities that the curriculum developers felt was necessary to prepare a physician to function in a leadership role in a range of operational assignments and environments. At our request, University officials identified the hours of its curriculum devoted to medical readiness topics. According to those officials, University medical students receive an estimated 734 hours of readiness training (including both classroom and field exercises). They also receive at least 50 hours of medical readiness training during the officer basic training that they are required to attend before beginning their first year at the University. Thus, by the time they graduate, University medical students have received between 784 and 889 hours of readiness training, depending upon the service branch involved. Service training officials and guidance indicate that the objectives of the initial readiness training usually provided to other military physicians are to teach physicians the fundamentals of military officership and the basic skills needed to treat combat casualties on the forward points of the battlefield. New military physicians who are graduates of civilian medical schools typically receive less initial readiness training than that provided to University students. For example, Air Force physicians who attend only the required basic officer training receive 50 hours of readiness training. If they were to also attend the optional Combat Casualty Care Course (C4), the total number of hours would increase to about 132 hours. Figure 3.3 compares the total number of hours of initial readiness training depending upon the source or sources through which the training was acquired. The portions of the University’s curriculum related to military medicine cover 17 broad areas, some of which are primarily medical in nature, some of which are primarily military. With less total time spent on initial readiness training, the amount of time spent on any individual topic generally is less for other physicians than for students at the University. However, some of the topics that the University program covers receive no coverage in the initial training given to other physicians (either in basic officer training or C4.) For example, the two areas that receive the most coverage in the military portion of the University’s curriculum are tropical medicine (66 classroom hours) and weapons effects (59 classroom hours.) Tropical medicine is not covered by the initial readiness training for other physicians in any service. Air Force physicians receive 30 minutes of coverage on weapons effects as part of their initial training; Army and Navy physicians receive none. Appendix II compares the hours of training provided by each source. University and other DOD officials view the difference between the University’s program and the medical readiness training provided to other military physicians to be more than a matter of extent and content. These officials point out that the information the University provides concerning military medicine is interwoven throughout all of its classes, including the basic sciences—not merely in the classes dedicated to military medicine. They view the University’s program as fundamentally different from readiness training in that it is a complete program of education. We obtained the perspectives of 44 commanders of major military medical units about the relative capabilities of University graduates and their civilian-educated peers. The responses received were narrative in nature and did not lend themselves to tabulation. However, the overall tenor of the comments was favorable to the University, even though most of the respondents were graduates of other accession programs. According to nearly all the medical commanders that we contacted, University graduates are at least initially better prepared for military medicine when compared with their peers. Only one commander viewed University graduates as no better prepared than their peers for the practice of military medicine. The remainder perceived, among other things, that physicians from the University have a greater overall understanding of the military, greater commitment to the military, better preparation for operational assignments, and better preparation for leadership roles. Some commanders noted that the advantage of the University medical education diminishes over time. Others expressed the view that the University and civilian medical schools should be regarded as complementary accession sources. “ produces physicians that are not only technically competent, but are also able to quickly function as . . . military officer. They are already familiar with the military corporate culture, which enhances their credibility and allows them to progress more rapidly into leadership positions. Civilian graduates are less equipped to do so and, in many cases, have no interest in doing so.” “ graduates. . . seem to adjust better to field conditions when deployed for operations or exercises. Having had some experiences with field medicine during their training, they know what to expect when they are called to a battalion aid station to provide support. The civilian school physician is often shocked by . . . first encounter with field medicine in terms of the austerity and the age of the equipment and pharmaceuticals he is expected to use. In a combat or scenario, that initial shock can be disastrous for the patients unless the physician adjusts quickly and learns to make do with what is at hand.” “ generally seem better prepared for field duty during the first few years of service. . . . students are taught military bearing and know how to act around soldiers. As time passes, the advantages of being schooled in a military environment become less apparent and do not appear to play a role after the two or three years that civilian graduates take to become accustomed to their Service requirements.” “ is necessary to provide a corps of physicians who have the knowledge base and experience to practice medicine in a military environment. This will provide a substantial amount of tomorrow’s leaders. But I don’t want to underemphasize the importance of the civilian-trained physicians. They bring in a wealth of diverse training that ensures the services will have personnel experienced in the latest procedures and techniques of civilian medicine.” Objective evidence is lacking concerning the relative effectiveness of the University and traditional readiness training programs. Neither University officials nor others we contacted within DOD were aware of any specific studies done for the purpose of comparing the effectiveness of the two approaches for providing readiness training. They were also not aware of databases that track information that would permit such an analysis. University officials said that they do not have a formal process in place to assure themselves that the military portions of their curriculum are appropriate to meet the needs of their customers. They do not seek an official endorsement of their curriculum by the services or DOD (although the Board of Regents includes the Surgeons General and a representative from the Office of the Assistant Secretary of Defense, Health Affairs.) The validity of other medical readiness training is uncertain as well. For example, the Chief of the Joint Medical Readiness Training Center (which administers C4) said that C4 has remained essentially unchanged since its start in 1980. The ultimate measure of a physician’s medical readiness is performance in an actual military deployment. We and others have reported that physicians were not adequately qualified for immediate deployment to Operation Desert Shield/Desert Storm because they lacked the required readiness training. For those physicians who were deployed, readiness skills were not comprehensively tested because the military suffered few casualties. Likewise, other recent deployments have not fully tested physician readiness capabilities to the extent that could be expected in a major conflict. In peacetime, the services have not routinely assessed the readiness capabilities of their physicians. Thus, neither recent actual deployments nor peacetime simulations have provided a basis to compare the performance of University graduates with their civilian-educated peers. DOD and the services lack agreement concerning the medical readiness knowledge and capabilities that physicians need. The services offer training courses to enhance and sustain the medical readiness capabilities of physicians; however, only one course—officer basic training—is explicitly required for all military physicians. Without agreed upon standards, the validity and effectiveness of University and other readiness training programs cannot be readily assessed. While University graduates have more readiness training than their contemporaries, the value of that training to DOD and the services cannot be objectively assessed from a requirements standpoint. In March 1995, DOD recognized the need for improvements in medical readiness training and set out to develop and establish medical readiness requirements and standards. Only against such standards can the validity of the current program at the University and of the training provided by the services be fully assessed. To help meet LCME standards required for accreditation as an academic institution, the University engages in several activities in addition to operating its School of Medicine. These fall generally into two major categories: (1) education and training activities and (2) research, consultation, and archival activities. Financial support for these activities, mostly the salaries and benefits of the University’s faculty and staff, is provided through the University’s general budget process. Although these are included in our computation of the cost to educate University medical students, we did not evaluate these activities in detail. In response to advances in science and medicine, medical schools have assumed responsibility for or participated in other programs in medicine and related fields that complement their programs leading to the Medical Doctor degree. LCME believes that the education of medical students is best conducted in such enriched environments. Our review of University documents and discussions with University officials showed that the University conducts several activities that correspond to LCME standards. Currently, the University is the only military organization conducting some of these functions, such as providing overseas physicians with required continuing medical education and maintaining a database on casualty wound treatment cases. University officials stated that if the University was not performing these roles, DOD would need to identify other providers. The University provides medical education beyond that provided by the School of Medicine and also conducts training and education for other health care and related professions. This mission is consistent with the LCME standards that medical schools should include programs for postdoctoral fellowships, graduate education in the basic medical sciences, continuing education for physicians, and education in other health professions and allied fields. Health professionals, particularly physicians, must acquire certain levels of continuing education to maintain their licenses. In fiscal year 1994, according to a University report to the Office of the Secretary of Defense, the University’s Office of Continuing Health Professional Education conducted about 600 continuing educational programs, attended by about 11,000 individuals, mostly military physicians. The largest programs are provided for physicians in Europe, East Asia, and the Pacific, thereby avoiding the costs of these physicians traveling to U.S. facilities for training. Examples of the courses provided include video endoscopy, obstetrics ultrasound, and laparoscopic cholecystectomy. The University is also developing the use of videoconferencing and computer networking to present its training. The University also provides certification for those trained in cardiac resuscitation courses. LCME accreditation standards also encourage medical schools to provide or be affiliated with institutions that provide programs in GME. (As mentioned in chapter 1, GME programs, which are usually 3 to 7 years in duration, provide physicians training in their chosen specialty.) The University is the academic affiliate for several military GME programs, including three in the Washington, D.C., area, providing faculty development, research, curriculum enhancement, and patient care. In addition, the University’s Office of Graduate Medical Education conducts DOD-wide consultation and oversight for 11 GME programs sponsored or co-sponsored by the University. DOD plans to assign the University with other responsibilities to ensure that military GME programs maintain their standards of quality for a smaller military force. In addition to its continuing education offerings, the University offers master’s and Doctor of Philosophy (Ph. D.) programs in anatomy, biochemistry, pharmacology, and other sciences. Between 1977, when the first students were admitted, and 1994, the University awarded 128 Ph.D. and 238 master’s degrees. These graduates form a pool of researchers and potential instructors at the University or other institutions. The University also conducts smaller, more specialized programs, such as a Ph.D. program in clinical psychology for selected military officers. The 1993 Defense Appropriations Act directed the University to implement a training program for nurse practitioners. Currently, the University operates accredited masters’ nurse programs for family nurse practitioners and for nurse anesthetists. The students are military officers who incur 4 additional years of obligated service for the 2-year course. The number of students entering the program are shown in the following table. The University conducts several research and archival activities both to meet its accreditation requirements and to advance the practice of military medicine. The research, consultation, and archival activities are conducted by faculty and staff in many departments of the University, including special centers for (1) casualty care research, (2) traumatic stress studies, and (3) preventive medicine and public health. The activities of each of these centers are summarized below. Casualty Care Research Center: This center researches and investigates issues related to injury control, casualty care, and disaster medicine. The center employs medical and graduate students and full-time staff to conduct its research, maintain a database of casualty care cases, and provide consultation to other federal, state, and local government agencies. A key activity of the Casualty Care Research Center is the Counter Narcotics Tactical Operations Medical Support program—a week-long course for emergency medical technicians and paramedics who operate as part of tactical law enforcement teams. Among other topics, this course covers medical care while under fire, hostage survival, effects of ballistic wounds, and evidence preservation. The staff also provides consultation to law enforcement agencies. Another mission of this center is maintaining the Wound Data and Munitions Effectiveness Team, which contains information on the tactical engagement, weapons employed, resulting injuries, and treatment of approximately 8,000 Vietnam combat casualties. Its collection of photographs, X rays, recovered bullets, and other data is the only one of its kind. Center for Traumatic Stress Studies: This center conducts research, maintains archives of medical literature, and provides consultation for psychiatric responses to trauma and disasters. Staff also collect on-site data to facilitate longitudinal follow-up on disasters and traumatic events. To illustrate, in 1992 a University psychiatrist traveled to Florida within 48 hours of Hurricane Andrew to provide emotional assistance to base personnel and evacuees from Homestead Air Base. To increase its knowledge in helping future victims, the University has surveyed participants in military engagements (such as the Gulf War) and natural disasters (such as Hurricane Andrew) to identify their emotional problems and how to help them. Centers for Preventive Medicine and Public Health: These centers develop databases and analytic methodologies, and prepare curricula for and evaluate processes and outcomes in clinical practice. They serve program managers and policymakers in DOD, other federal agencies, local governments, and private organizations concerned with health policies and services. These centers address topics that receive little attention in many civilian medical schools but are critical to the practice of military medicine, such as foreign area medical studies, landscape epidemiology, and health in extreme environments. DOD’s need for physicians has changed as a result of the emergence of smaller regional threats at the end of the Cold War and the overall downsizing of the military in response to large budget deficits. Our review of DOD retention data shows that University graduates have the longest expected retention among physicians from the various accession sources. Because a higher percentage of University graduates are expected to reach retirement (20 years), they contribute to DOD’s long-term need for physicians and for medical specialists considered critical for wartime needs. Scholarship program graduates, who are the largest source of military physicians, generally have shorter careers. Although DOD is reevaluating its future need for physicians, it has not reached conclusions about the number of physicians needed or the optimal length of time that physicians should serve. While the longer pay-back obligation of University graduates is a key factor in their retention, factors such as age, marital status, compensation, nonphysician duties, and working conditions have also been associated with physician retention. If DOD continues to need a cadre of experienced career physicians, alternative strategies such as an enriched scholarship component could be considered as a potentially more cost effective way to meet DOD’s long-term need for physicians. In 1972, when the University and the scholarship program were authorized, the University was expected to supply DOD’s long-term needs for military physicians, while the scholarship program would supply the majority of physicians for short-term needs. Early graduates of both accession programs are still several years from retirement eligibility. Our efforts to determine whether graduates of both programs had satisfied their pay-back obligations were hampered by incomplete information on other service commitments created by factors such as prior service, academy attendance, or extended GME training. We reviewed DOD’s retention databases to obtain estimates of the expected retention patterns for University graduates and scholarship program physicians. These databases incorporate information from retention experiences to date for University and scholarship program physicians and projections of their future retention based on historical experiences of physicians from other accession programs. DOD has offered scholarships since 1973, but few scholarship program graduates have served for 20 years to qualify for retirement. Our review of DOD retention data shows that regular scholarship program graduates on average are expected to provide 9.8 years of service, while deferred scholarship program graduates serve 5.3 years on average. Further, using DOD retention data, we project that 11 percent of the regular scholarship program and 3 percent of deferred scholarship program physicians from the class of 1994 will reach retirement. DOD’s retention experience with University graduates is also limited because the first class graduated in 1980. As a result, the most senior alumni have only 15 years of service. The DOD retention databases show University graduates are expected to provide about 18.5 years of service, and about 50 percent of University graduates are expected to stay on active duty service for 20 years or longer. The longer expected retention of University graduates is consistent with the legislative intent of providing long-term military medical officers. In addition, our analysis of DOD retention data shows that University graduates are retained at a higher rate in the medical specialties considered critical for the wartime mission. University graduates are expected to comprise a significant portion of the medical cadre needed for long-term leadership. For example, although University graduates were about 14 percent of the physicians who graduated in fiscal year 1994 (the remaining 86 percent being scholarship program participants), they are expected to comprise 47 percent of the members from this class who stay 20 years or longer. University graduates also have greater retention in those medical specialties considered critical for war. Current readiness planning considers the medical specialties of anesthesiology, orthopedic surgery, and general surgery to be critical for the wartime need. However, physicians in these specialties historically leave the military at faster rates than those in other specialties. For example, Navy officials estimate that, each year, the Navy loses about 22 percent of physicians in these specialties, compared with an annual 11 percent loss for all physicians. A review of Army data shows that a larger percentage of University graduates are retained in these critical specialties than are graduates of the scholarship program. The Army data show that, on average, 31 percent of University graduates in the three critical medical specialties will stay 20 years, compared with 12 percent from the regular scholarship program and 2 percent of deferred scholarship program graduates. DOD’s ability to adapt to the changing nature of operational scenarios and the challenges of providing cost-effective peacetime health care will be key factors in determining physician needs for the military. Although recent DOD studies suggest that large reductions have occurred in the overall number of physicians, these studies do not indicate the optimal retention needed for physicians from the various accession programs. DOD’s evaluations of its future physician needs have not led to conclusions about the number of physicians required or optimal retention patterns. The catalyst for these evaluations was section 733 of the National Defense Authorization Act for fiscal years 1992 and 1993, which required DOD to conduct a study to, among other things, determine (1) the size and composition of the military medical system needed to support U.S. forces during a war or other conflict and (2) the adjustments needed for cost-effective delivery of medical care to covered beneficiaries during peacetime. DOD’s study (referred to as the 733 study) estimated that DOD has as many as 3 times the number of physicians it needs during peacetime to meet projected wartime requirements, as shown in table 5.1. The base case in DOD’s study represents a 68 percent lower requirement than DOD’s fiscal year 1999 program plan suggests, but refers only to those active duty physicians needed to administer care to wartime casualties. It excludes the additional numbers of physicians needed for readiness during peacetime (the augmented case). In the augmented case, the study concludes that the number of active duty physicians could be lower by 50 percent. The 733 study results immediately prompted a review by the services of their physician needs. Although the services have not disagreed with the 733 study results, their individual efforts produced higher estimates of physician needs, primarily because their reviews were based on different assumptions than were used in DOD’s study. Our review of the 733 study and the service’s responses found that even if the services’ assumptions are correct, the resulting requirements for military physicians would be less than are currently planned for in 1999. The 733 study did not present a precise estimate of DOD’s needs or a precise guide for deciding which medical personnel, units, and capabilities are no longer required. Issues such as these must be resolved before DOD can make decisions about its retention needs. Since 1991, the total active duty physician force has dropped about 4 percent, from about 14,200 in 1991 to about 13,700 in 1994. Further reductions to about 12,600 are scheduled by 1999 (11 percent overall). However, according to service officials in the Offices of the Surgeon General, most of the reductions between 1991 and 1994 were due to the normal attrition of physicians through retirement, resignations, and administrative leave. Navy officials also said some physicians were allowed to transfer from active duty to reserve status, mostly as a result of base closures. These reductions in active duty physicians are slight when compared with reductions in the entire force over the same period. Between 1991 and 1994, total military endstrength dropped about 20 percent, from 2.O million to 1.6 million, and is expected to drop to 1.45 million by 1999 (about 28 percent). Service officials cited congressionally imposed limits with respect to reductions of health care personnel and DOD’s continuing responsibility to provide care to beneficiaries of DOD’s health care system as reasons why greater reductions have not occurred in the physician force. Section 711 of the National Defense Authorization Act for fiscal year 1991 prohibits reductions in military (and civilian) health care personnel below the number of such personnel serving on September 30, 1989, unless DOD certifies to the Congress that (1) the number of personnel being reduced is in excess of current and projected needs and (2) that the reduction will not increase costs in the $3.6 billion DOD-administered health insurance program for beneficiaries—the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). DOD is also prohibited from reducing the number of Navy active duty medical officers to fewer than 12,510 (including nonphysicians) unless DOD certification is accomplished. Our review of the DOD certification documentation for fiscal years 1991 to 1995 indicated that the Army has led in the reduction of its physician force. In fiscal year 1995, the Army was given authority to reduce its physician force by 553 physicians after certifying this number was in excess of their requirements and would not result in increased CHAMPUS expenses. The Assistant Secretary of Defense for Health Affairs, as part of the fiscal year 1995 DOD certification, requested the repeal of all legislative provisions that prohibit medical staff reductions. Officials in the Navy and Air Force stated that they have not sought to reduce the number of physicians because they have not been able to obtain and retain the targeted number of physicians they believe they need. For several years, DOD has been testing alternative approaches to delivering health care that increasingly incorporate managed health care techniques. In this regard, DOD recently established its TRICARE program as an alternative to the traditional CHAMPUS fee-for-service health insurance plan covering beneficiaries of active duty members. TRICARE is intended to provide an economical source of medical care for all DOD beneficiaries even as medical service endstrength is reduced. A key component of TRICARE involves contracting with civilian health care providers for beneficiary health services. If TRICARE is successful, it could result in a reduced need for active duty physicians as more care is provided by civilian contractors. Progress made in the implementation of TRICARE was one of the reasons mentioned by the Assistant Secretary of Defense for Health Affairs for the proposed repeal of legislative provisions that prohibit medical staff reductions. University graduates are retained in the military at higher rates than other accession sources largely because of their longer pay-back obligations. Also, some University students, such as those who graduate from the military academies and the Reserved Officer Training Corps (ROTC) programs, have existing obligations before becoming University students. Overall, many factors are associated with the decision to make the military a career, including demographic and personal concerns such as age and family considerations, compensation, and nonphysician activities. Although DOD’s retention data indicate a relationship between retention and accession source, the data do not indicate the reasons why these patterns occur. However, the longer obligation pay-back requirement is a key factor in the longer retention of University graduates. University graduates are expected to serve for about 11 years after graduation, including GME training, before they are first able to leave military service; compared to about 8 years for the regular scholarship program and 4 years for deferred scholarship program graduates. This longer pay-back obligation period is expected to lead many University graduates to decide to serve another 9 years until they are able to retire. University officials said the longer retention may be partially due to their recruitment criteria, under which they specifically attempt to select people who express an interest in making the military a career. Hence, the longer retention is consistent with students’ stated intentions. Prior military obligation on the part of some of its students may also influence University retention. Two 1994 military studies identified military academy backgrounds, prior military experience, University attendance, and fellowship training as predictive factors in the retention of physicians in certain specialties. About 21 percent of all students at the University have attended the military academies or participated in ROTC programs. We previously reported that retention of these officers, regardless of profession, is high. Another 25 percent of all University students had prior military experience in that they were either currently on active duty at the time they enrolled or they had prior active duty or reserve experience. Many of these predictive factors could apply to scholarship program graduates as well. For example, Army scholarship program officials suggested that the retention experience of ROTC and military academy graduates in the scholarship program is similar to that of University graduates from the same sources. Moreover, scholarship program recruiters also look for people who are interested in making the military a career. Lower retention among deferred scholarship program graduates has been attributed to the fact that they are better able to network in the civilian sector during their civilian GME programs and create private sector opportunities for themselves. One DOD official who has contributed to a number of DOD retention studies believed the retention patterns for all physicians who stay 12 years is about the same, regardless of accession source. Many other factors influence physicians’ decisions to stay in or leave the military. For example, personal characteristics, such as age and sex, family considerations, and working conditions have all been found to influence physicians’ decisions. More often than not, financial considerations have been identified as a significant factor in retention. For example, in 1990, we conducted a survey of 1,500 military physicians to determine the factors that most influence their decisions to leave the military. Time spent on nonphysician tasks and gaps between military and civilian compensation were the most significant factors identified. Physicians also reported dissatisfaction with other aspects of military service, such as poor hospital equipment, the inability to provide continuity of care to patients, excessive amounts of quality assurance tasks, and limited opportunities to attend professional meetings and training. Although many factors affect retention, a key DOD official involved in DOD retention studies said that the options available to DOD to change retention patterns are limited. For example, there may be little that can be done about dissatisfaction with quality assurance procedures because these are needed for hospital accreditation. The official also said that even in those areas where DOD might have some control, such as physician compensation, there are limits on the amounts that DOD can pay. Moreover, he believes that for some medical specialties, DOD could not match the compensation that these physicians could earn in the private sector. Other studies that examined why physicians stay in the military identified the following reasons: the availability of teaching assignments and clinical research opportunities; lack of worry about malpractice and office management problems; more control over working hours; the collegial atmosphere of military medicine; and the opportunity to travel. Proponents of the University note that the University meets DOD’s need for a small cadre of experienced military officers and leaders who, in their opinion, are better prepared for the special needs of military medicine. If the University is closed and DOD continues to need experienced career military physicians, DOD will need to find alternative ways to extend the careers of some military physicians while enhancing their exposure to military readiness training. One approach could involve an enriched component to the scholarship program which would require a longer pay-back obligation for selected students in return for additional benefits, training, and military career opportunities. Additional readiness training could be provided through a post graduate period specifically designed to enhance the physician’s preparation for the special needs of military medicine. Through this type of two-tiered scholarship approach, DOD could address its short- and long-term requirements for military physicians. When the University and the scholarship program were authorized by the Congress in 1972, following the end of the military draft, they were intended to be complementary physician accession programs. • The University was established to meet the need for a small cadre of physicians who would be likely to become career military officers and leaders. • The scholarship program was authorized to provide a continuing and larger supply of military physicians who would, for the most part, not be expected to serve until their retirement. Notwithstanding the intended complementary nature of the two physician accession programs, the comparative cost-benefit and cost-effectiveness of the programs have been the subject of debate ever since their authorization. Our prior work, this report, and several studies by other groups over time show that by most measures the University program is a more costly physician accession program than the scholarship program. Nevertheless, those who advocate the continuation of the University make strong arguments that the need for a cadre of military physician career officers and leaders remains, and that the University fulfills that need well. University supporters also note that in addition to providing a high quality medical education, the University provides other benefits such as medical research and archival programs, required continuing medical education for overseas medical personnel, and graduate education programs for allied health professionals. University officials stated that if the University were not performing these tasks, other DOD components would have to be tasked to carry them out. The early retention history for University graduates indicates that the majority of them are still in the military and fulfilling their service obligations. Also, our review of DOD’s retention analyses shows that the University would likely continue to meet DOD’s needs for a cadre of military physician career officers. However, based on our review of available information, we believe that if the University were closed, these needs could be fulfilled by alternative strategies, such as adjusting the pay-back requirements of scholarship students, revising the training approach for those students to incorporate additional military unique training sessions, or doing both. In our view, issues relating to the changed need for military physicians in war and peacetime settings are important factors to be considered as decisionmakers debate the future of both the University and scholarship programs. The changed wartime scenarios, which point to a reduction in the number of physicians needed to meet contingency requirements should, in our opinion, be taken into account as the future existence and the possible size of the accession programs are determined. Moreover, DOD’s attempt to meet its peacetime care obligations to military beneficiaries through increased reliance on its TRICARE managed care program will also affect the number and type of physicians that DOD needs. The Administration’s National Performance Review has proposed that the University be closed. This proposal has presented the Congress with difficult policy decisions regarding the need for a cadre of physicians who are likely to become career military officers and the most appropriate means of retaining those physicians. As Congress makes those decisions, it may wish to consider requiring DOD to justify both the University and the scholarship program in the context of DOD’s specific short- and long-term requirements for military physicians, the role of the University and the scholarship program in satisfying those requirements, and their relative costs. We obtained comments on a draft of this report on September 15, 1995, from the Assistant Secretary of Defense, Health Affairs, and his staff and from the University’s President and other top University officials. The Assistant Secretary stated that the report presents a great deal of factual data and reflects a significant research effort in its collection and compilation. Both the Assistant Secretary and University officials were concerned, however, about several presentational issues including what they viewed as • a focus in our comparative cost analysis on the cost per graduate of each program, rather than on the total cost to the taxpayer per staff year of DOD service, which they believe is the appropriate measure of cost; • a lack of emphasis on the activities of the University, which results in cost-avoidance for other DOD components; and • a lack of emphasis on the University’s unique contribution to providing military physicians schooled in militarily unique medical subjects and our failure to acknowledge the “acculturation process” provided by the University in meeting the needs of military medicine. In response to our matter for congressional consideration, the Assistant Secretary stated that, although the position of the Administration and the Department is that the University should be closed, the Department noted our recognition of the different goals of the two programs and their complementary nature. He also stated that the Department does not believe additional justification is needed for the University and scholarship program and that the need for a long-term experienced cadre of military physicians produced by the University and short-term physicians will continue. Regarding the first concern of DOD and the University, we recognized that there can be and, in fact, have been several units of measurement used to compare the relative costs of DOD’s physician accession programs. Rather than offering one unit of measurement, we have presented, in an iterative way, several units of measurement that we believe present a complete comparative analysis of the programs. We have revised the report to further emphasize the cost-avoidance activities of the University but, as stated earlier, we did not validate the University’s estimates of cost-avoidance. The Assistant Secretary and University officials were concerned that we had not appropriately emphasized the University’s unique contribution to military medicine. In response, we have revised the report to reflect the University’s approach to providing a complete education in military medicine and made minor adjustments to the draft report. These adjustments were designed to attribute statements about the unique needs of military medicine and the University’s contributions without appearing to question the credibility of our sources. However, we believe that judgments regarding the relative emphasis placed on various issues discussed in the report must be based on the evidence at hand. In this case, the evidence was based primarily on our review of military medical literature and discussions with military medical personnel who provided their opinions regarding the uniqueness of military medicine. Finally, in developing the matter for congressional consideration, we did not envision that DOD would have to provide additional justification for the accession programs. Rather, we believe that the two programs need to be discussed in the context of DOD’s specific short- and long-term requirements for military physicians so that decisions regarding the continued need for the programs and their relative sizes can be made with confidence that the requirements will be adequately met. Department and University officials offered several technical comments on our draft report that we incorporated into the final report as appropriate.

Summary: Pursuant to a legislative requirement, GAO reviewed the Department of Defense's (DOD) Uniformed Services University of the Health Sciences (USUHS) and Health Profession Scholarship Program (HPSP), focusing on: (1) the cost of obtaining military physicians from all sources; (2) the quality of medical education provided by the University; (3) how physicians are trained to meet military medical needs; and (4) retention rate patterns among USUHS and HPSP. GAO found that: (1) by most measures, USUHS is the most expensive source of military physicians; (2) HPSP provides the majority of military physicians; (3) when all federal costs are considered, USUHS nearly equals the cost of the regular scholarship program and is less costly than the deferred scholarship program; (4) USUHS graduates are expected to have longer military careers, and USUHS receives less non-DOD federal support than civilian medical schools and graduate training programs; (5) the quality of USUHS medical education compares well with that of all medical schools and its graduates' abilities are at or above those of other military physicians; (6) although USUHS graduates appear to be better trained in military medicine than their civilian peers, the significance of their additional readiness training is unclear; (7) if USUHS is closed, USUHS officials believe that DOD would need to continue funding other USUHS services, such as academic affiliation for several military graduate medical education programs, training and education for other health care and related professions, and research, consultation, and archival activities; (8) on average, USUHS graduates, particularly those in critical military medical specialties, tend to remain longer in the services than civilian-educated physicians; and (9) because its changing physician needs are not known, DOD needs to assess whether alternative strategies for obtaining certain experienced, long-term physicians at less cost are available.